The Pillars of Biloxi

In the surveyor’s words

From the most serious findings on record at The Pillars of Biloxi, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Apr 3, 2025

  Based on observation, interviews, record review, and facility policy review, the facility failed to provide adequate supervision and ensure environmental safety to prevent Resident #1, a vulnerable resident, from exiting the facility unnoticed and unsupervised for one (1) of three (3) residents reviewed. Resident #1 On 3/23/25, Resident #1, who had a Brief Interview for Mental Status (BIMS) score of eight (8), physically pushed out and removed the window screen in his room and exited the building. Resident #1 exited the facility unnoticed and was last seen inside the facility at 6:00 AM by a Certified Nursing Assistant (CNA) and was found at 6:30 AM by facility staff (Dietary Cook) who was reporting to work. […]

• Immediate jeopardy, isolatedF656Aug 14, 2024

  Based on interviews, record reviews, and facility policy review, the facility failed to implement care plan interventions related to wandering/elopement risk for one (1) of four (4) resident care plans reviewed. Resident #1. The facility's failure to implement care plan interventions resulted in Resident #1 exiting the facility unsupervised and unnoticed by facility staff. Facility staff took Resident #1 to the therapy gym at approximately 9:50 AM on 8/8/24. She was determined to be missing at 9:55 AM and was found at 10:23 AM, about one (1) mile from the facility. […]

• Immediate jeopardy, isolatedF689Aug 14, 2024

  Based on interviews, record reviews, facility policy reviews, and the facility's investigation, the facility failed to provide adequate supervision to prevent Resident #1, who was identified as an elopement and wandering risk, from exiting the facility unnoticed and unsupervised for one (1) of four (4) residents reviewed. The facility's failure to provide supervision resulted in Resident #1 exiting the facility unsupervised and unnoticed by facility staff. Resident #1 was brought to the therapy gym at approximately 9:50 AM on 8/8/24 and left unattended. She was determined to be missing at 9:55 AM and was found at 10:23 AM, about one (1) mile from the facility. […]

• Actual harm, isolatedF656Mar 21, 2025

  Based on interviews, record review, and facility policy review, the facility failed to implement comprehensive care plan interventions for a resident who was identified as a fall risk, resulting in a fall that caused the resident to sustain a mildly displaced fracture of the proximal right humerus, for one (1) out of three (3) sampled residents. Resident #1. Findings include: A review of the facility's Care Plans, Comprehensive Person-Centered, reviewed 10/2022, revealed: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .9. […]

• Actual harm, isolatedF689Mar 21, 2025

  Based on interviews, record review, and facility policy review, the facility failed to provide adequate supervision to prevent Resident #1, who was identified as a fall risk, from falling and causing the resident to sustain a mildly displaced fracture of the proximal right humerus for one (1) out of three (3) sampled residents, Resident #1. Findings include: A review of the facility's Safety and Supervision of Residents, reviewed 8/2023, revealed: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The record review of the facility investigation revealed Resident #1 had a witnessed fall on 2/13/25 at 6:49 AM. […]