Vineyard Court Nursing Center

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

the other residents, staff, and camera. Resident #1 was on the side and facing Resident #1. The staff were positioned in the center of the area and only had a view of Resident #2's back. The Administrator confirmed

the staff should have been positioned on each end of the rectangular area to offer a better view of all of the residents to ensure safety. She confirmed the facility failed to provide adequate supervision during smoking break and due to this a resident was able to light a marijuana joint, smoke it, and pass it to another resident who also smoked it. Review of Resident #1's Safe Smoking Evaluation dated 3/21/25, 4/10/25, and 6/6/25 revealed the box by Resident is safe to smoke unsupervised at this time was not checked.Record review of Resident #1's admission Record revealed he was admitted to the facility on [DATE REDACTED] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction and pain.Record review of Resident #1's Minimum Data Set (MDS) Section C with Assessment Reference Date (ARD) of 6/16/25 revealed a Brief

Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact.Review of Resident #2's Safe Smoking Evaluation dated 4/10/25, 8/14/25, and 8/27/25 revealed the box by Resident is safe to smoke unsupervised at this time was not checked.Record review of Resident #2's admission

Record revealed resident was admitted to facility on 3/3/25 with diagnoses that included cerebral infarction.Record review of Resident #2's MDS Section C with ARD of 6/4/25 revealed a BIMS score of 14 which indicated the resident was cognitively intact.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Vineyard Court Nursing Center

2002 5th Street North Columbus, MS 39705

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observations, staff and resident interviews, record review, and facility policy review, the facility failed to provide an ordered pain medication for a resident who had pain for one (1) of four (4) residents reviewed.

Resident #1Findings include:Record review of facility policy titled, Pharmacy Services dated 3/14/24, revealed, It is the policy of this facility to ensure that pharmaceutical services, whether employed by the facility or under an agreement, are provided to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice. Record review of facility policy titled, Medication Shortages/Unavailable Medications with revision date of 1/1/13, revealed, Upon discovery that facility has an inadequate supply of a medication to administer to a resident, facility staff should immediately initiate action to obtain the medication from Pharmacy.2.2 If the next available delivery causes delay or a missed dose in the resident's medication schedule, Facility nurse should obtain the medication from the Emergency Medication Supply to administer the dose. During an interview and observation on 8/26/25 at 3:35 PM, Resident #1 appeared comfortable in his room lying in his bed. He stated he had pain

in his back and his feet, but was comfortable at that time. He stated he recently requested pain medication for the pain in his back and feet and he was told by the nurse that he did not have pain medication and he would have to wait until it arrived at the facility. During a phone interview on 8/27/25 at 11:15 AM, Licensed Practical Nurse (LPN) #1 revealed she was working the medication cart on the evening that Resident #1 requested pain medication, and it was unavailable. She informed him that the medication was unavailable, and he could not receive it at that time, but he did receive his other medications as scheduled. She stated

she had another resident with a medical concern and got distracted by that issue and failed to follow through with obtaining the medication as needed and ordered. She acknowledged she dropped the ball and that it was my mistake and took full responsibility for not obtaining the medication as needed. Interviews with the Administrator on 8/27/25 at 9:45 AM and at 1:30 PM revealed the facility had a procedure in place to ensure each resident received the medications needed and ordered, but this procedure was not followed by LPN #1. She stated the resident had an active prescription and the nurse should have contacted the pharmacy for a code to the medication dispensing system to obtain the medication to administer to the resident. She confirmed the facility failed to provide an ordered pain medication for a resident who had pain. She confirmed the medication system was in place, but the staff member did not follow the procedure, therefore, the medication was not administered. Record review of Resident #1's Order Summary Report revealed an order for Hydrocodone-Acetaminophen tablet 7.5-325 milligrams - give one tablet by mouth every four hours as needed for severe pain. Record review of Resident #1's Controlled Substances Proof of Use with received date of 6/19/25 revealed resident completed a card of Hydrocodone 7.5-325 on 8/9/25 at 8:48 PM. Record review of Resident #1's Controlled Substances Proof of Use with received date of 8/12/25 revealed the facility received Hydrocodone 10-325 on that date.Record review of Resident #1's Electronic Medication Administration Record (EMAR) for August 2025 revealed resident received his as needed Hydrocodone on 8/9/25 at 8:48 PM then did not receive again until 8/11/25 at 12:50 PM.Record review of Resident #1's admission Record revealed he was admitted to the facility on [DATE REDACTED] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction and pain.Record review of Resident #1's Minimum Data Set (MDS) Section C with Assessment Reference Date (ARD) of 6/16/25 revealed a Brief

Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact.

Event ID:

Facility ID:

If continuation sheet