Premier At The Springs
Inspection history, citations, penalties and survey trends for this long-term care facility in North Little Rock, Arkansas.
- Location
- 3600 Richards Road, North Little Rock, Arkansas 72117
- CMS Provider Number
- 045357
- Inspections on file
- 38
- Latest survey
- August 14, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Premier At The Springs during CMS and state inspections, most recent first.
The facility did not complete a thorough facility assessment to determine appropriate staffing and resource needs for all shifts, nor did it develop a plan for staff recruitment and retention. The assessment team lacked input from direct care staff and residents, and staffing decisions were based on census and minimal requirements rather than resident acuity or needs. Leadership interviews confirmed the facility assessment was not used to guide staffing or operational planning.
Staff failed to follow infection control protocols during wound care for a resident with a surgical wound, including not using barriers, reusing gauze, and improper glove changes. Additionally, two glucometers used for blood sugar checks on multiple residents were not disinfected according to manufacturer guidelines, as an LPN used alcohol pads instead of the required germicidal wipes.
Two residents did not receive necessary assistance with personal hygiene and nail care, despite being unable to perform these activities independently. One resident, with a recent amputation and diabetes, was not assisted with shaving as requested, resulting in significant facial hair growth. Another resident, with paralysis and chronic illness, had long, curled, and discolored toenails that were not addressed despite repeated reports to staff. Facility policies and staff interviews confirmed the expectation for such care, but it was not provided in these cases.
A resident with severe cognitive impairment and on hospice care was the subject of an abuse allegation that was not reported to law enforcement as required by facility policy. Despite internal investigation procedures, there was no evidence of a police report or incident number, and interviews confirmed that the required notification to law enforcement did not occur.
A resident with severe cognitive impairment and limited mobility was observed using a wheelchair that remained visibly dirty over several days, with staff interviews confirming that cleaning was a night shift CNA responsibility. The facility lacked policies or in-service training for wheelchair cleaning, contributing to the failure to maintain necessary equipment in a clean and sanitary state.
The facility did not consistently post all required daily nurse staffing information, specifically omitting the actual hours worked by licensed personnel and, at times, the facility census. Observations confirmed that only staff assignments and numbers by category were displayed, and interviews with the DON and Administrator indicated the postings were intended for staff assignment purposes rather than full regulatory compliance.
A facility failed to accurately complete the MDS for a resident on hospice care. The resident, admitted with Moderate Protein-Calorie Malnutrition, had elected hospice services, but the MDS inaccurately indicated no prognosis of less than six months to live. The error was identified during a review with the MDS Coordinator, who confirmed the mistake.
A resident with respiratory failure and sleep apnea had a physician's order for oxygen therapy, but the care plan did not reflect this need. The MDS indicated the resident received oxygen, yet the care plan was not updated to include this treatment, contrary to facility policy.
The facility failed to ensure proper food storage and sanitation practices, including uncovered food items, improper refrigerator temperatures, expired food, unsanitary kitchen conditions, and inadequate hand hygiene and glove use by staff. These deficiencies had the potential to affect 108 residents.
The facility failed to maintain privacy and dignity for two residents. One resident was exposed during incontinence care without the privacy curtain being pulled, and another was transported uncovered on a shower bed. The CNAs involved acknowledged the lapses, and the DON confirmed the need for privacy measures.
The facility failed to accurately assess the comprehensive assessments for two residents. One resident with bipolar disorder was not correctly documented as PASSAR level II, and another resident with COPD was not accurately coded as a smoker in the MDS. The DON confirmed these inaccuracies, and the facility did not provide the surveyor with an MDS coding policy.
A resident with severe cognitive impairment and a Stage 4 Pressure Ulcer did not receive proper nail care and shaving as per the care plan. Observations and interviews confirmed that the resident's nails were dirty, and his beard was untrimmed, despite facility policies and care plans specifying regular maintenance.
The facility failed to ensure hydration was available at all times for a resident with a diagnosis of constipation. The resident reported not having water all day and often lacking water on weekends. Observations confirmed the absence of water, and a CNA admitted being too busy to pass water that day. The DON confirmed that residents should always have water available.
The facility failed to provide clean oxygen tubing and proper storage for oxygen tubing for two residents on oxygen therapy. Oxygen tubing was observed lying on the floor in one resident's room and not stored in a storage bag for another resident. Staff confirmed that the tubing should be replaced if found on the floor and stored in a bag when not in use.
The facility failed to conduct a side rail assessment for a resident with a Stage 4 Pressure Ulcer, despite the resident being observed with bed rails up on multiple occasions. Staff confirmed the use of side rails without proper assessment, contrary to the facility's 'Bed Safety' policy.
The facility failed to reduce a resident's Sertraline dosage from 125 mg to 100 mg as recommended by the physician. Despite the DON signing the recommendation, the resident continued to receive the higher dosage, and the DON could not explain the oversight.
The facility failed to serve meals according to the planned menu, resulting in residents on mechanical soft diets receiving incorrect portions of pork chili Verde and blackened chicken breast. This affected the nutritional intake of 27 residents on mechanical soft diets and 7 residents on pureed diets.
The facility failed to maintain an effective pest control program, resulting in multiple flies being observed in various areas of the kitchen during meal preparation and serving. Despite regular pest control services, the issue was not addressed, leading to the observed deficiency.
The facility failed to ensure call lights were within reach for several residents, including those with severe cognitive impairments and incontinence issues. Observations showed call lights on the floor, out of reach, despite staff acknowledging the importance of accessibility. This deficiency highlights a lapse in accommodating residents' needs for assistance.
A facility failed to complete a self-administration safety screen for a resident with multiple diagnoses, allowing the resident to have undocumented over-the-counter medications on their nightstand. The medications were observed multiple times over several days, and a self-administration assessment was only completed after the surveyor's observations.
The facility failed to update a resident's care plan to reflect the presence of an indwelling catheter, despite the resident's history of urinary issues and a physician's order for the catheter. The MDS assessment confirmed the catheter's presence, but the care plan was not revised accordingly.
A resident with an indwelling urinary catheter received improper peri care, including incorrect wiping and lack of catheter securing, leading to potential risks of dislodging and trauma. The DON confirmed the correct procedures were not followed, and the facility's policy did not address the specific deficient practice.
Failure to Conduct Comprehensive Facility Assessment for Staffing and Resource Needs
Penalty
Summary
The facility failed to conduct a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. The assessment did not specify staffing requirements for day, evening, night, or weekend shifts based on the needs of the resident population. There was no documented plan for staff recruitment or retention, and the assessment team did not include direct care staff or resident representatives. The assessment relied on census numbers and minimal state requirements rather than a detailed analysis of resident acuity or specific care needs. Additionally, the assessment was not referenced by staff responsible for scheduling or staffing decisions. Interviews with facility leadership revealed a lack of understanding and utilization of the facility assessment in staffing and operational planning. The ADON and DON indicated that staffing decisions were based on corporate direction and minimal state formulas, without reference to the facility's own assessment. The Administrator also did not use the assessment to determine staffing needs, instead relying on general federal requirements. The facility's policy required a detailed review of resident acuity and available resources, but this was not reflected in the actual assessment or in practice.
Infection Control Deficiencies in Wound Care and Glucometer Cleaning
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during wound care and blood glucose monitoring. During wound care for a resident with a surgical wound and wound vacuum on the left foot, the LPN did not follow established infection control protocols. Supplies were placed directly on an un-sanitized over-bed table without a barrier, and no protective barrier was placed under the resident's foot, resulting in purulent drainage contaminating the bed linen. The LPN reused gauze pads to clean the wound, did not change gloves between removing the old dressing and cleaning the wound, and used scissors that had been placed on an un-sanitized surface to cut wound care materials. After the procedure, items such as the skin prep spray and scissors were handled with ungloved hands and placed on the treatment cart without immediate sanitization. Additionally, the facility failed to ensure that glucometers were cleansed according to the manufacturer's guidelines between resident uses. An LPN was observed performing fingerstick blood sugar checks on multiple residents using two glucometers, but did not properly disinfect the devices between uses. Instead of using a registered disinfectant or germicidal wipe as required by the manufacturer, the LPN used alcohol pads to clean the glucometers and only did so after multiple uses. The LPN stated that she had been instructed by management to use alcohol wipes, although the DON was unaware of this change and confirmed that germicidal wipes were the expected method. Facility policy for wound care required establishing a clean field, using barriers to protect linens, performing hand hygiene, changing gloves appropriately, and sanitizing reusable items before returning them to the treatment cart. The policy for glucometer cleaning aligned with the manufacturer's guidelines, which specified the use of a registered disinfectant or bleach solution. These protocols were not followed during the observed incidents, resulting in deficiencies in infection prevention and control.
Failure to Provide Personal Hygiene and Nail Care Assistance
Penalty
Summary
The facility failed to provide necessary personal care and assistance with activities of daily living for two residents who were unable to perform these tasks independently. One resident, admitted with multiple diagnoses including a recent amputation, diabetes, and vascular disease, was documented as requiring moderate assistance with personal hygiene. Despite being cognitively intact and expressing a clear preference to remain clean-shaven, the resident reported only receiving a shave once in the facility's barber shop, for which they had to pay. Over several days of observation, the resident continued to have a significant growth of facial hair, and staff interviews confirmed that CNAs were responsible for assisting with shaving but had not consistently provided this care as requested by the resident. Another resident, admitted with a history of stroke, paralysis, and chronic illnesses, was identified as having a self-care deficit and required assistance with nail care. Although records indicated that the resident's nails were checked regularly, direct observation revealed that the resident's toenails were long, curled, discolored, and jagged. The resident confirmed that the condition of their toenails was bothersome and had been reported to nursing staff multiple times. Interviews with CNAs and nursing staff revealed that there was an established process for nail care, particularly for residents with diabetes or other complicating conditions, but the process was not followed in this case. The resident was not listed for podiatry care, despite the need for professional attention to their toenails. Facility policies required that residents unable to perform activities of daily living independently receive necessary services to maintain grooming and hygiene, and that foot care be provided in accordance with professional standards. Staff interviews confirmed awareness of these policies and the procedures for providing or escalating care needs. However, the failure to provide timely and appropriate assistance with shaving and toenail care for these two residents resulted in unmet personal care needs, as directly observed and reported during the survey.
Failure to Report Abuse Allegation to Law Enforcement
Penalty
Summary
The facility failed to ensure that an abuse allegation involving a resident with severe cognitive impairment was reported to law enforcement as required by facility policy. The resident, who was receiving hospice care and had significant cognitive and communication deficits, was the subject of an internal abuse investigation initiated after an allegation was reported. Upon review of the facility’s investigation records, there was no evidence of a police report or incident number related to the allegation. Interviews with the Administrator and DON confirmed that reporting abuse allegations to law enforcement was part of the facility’s established process. However, the police officer identified by the Administrator as having received the report stated that no such report was made on the specified day, nor was there any record of a report for the entire month in question. The facility’s policy explicitly required immediate notification of law enforcement officials in cases of suspected abuse, neglect, exploitation, or misappropriation.
Failure to Maintain Resident Wheelchair in Clean and Sanitary Condition
Penalty
Summary
The facility failed to ensure that necessary equipment, specifically a resident’s wheelchair, was maintained in a clean and sanitary condition. Over multiple days of observation, the wheelchair assigned to a resident with severe cognitive impairment and limited mobility was found to have visible dirt, white and brown flakes, and crumbs caked on the seat cushion and frame. The resident, who had diagnoses including hypertensive heart disease, vascular dementia, and acute kidney failure, reported that the wheelchair had been dirty for a long time. Staff interviews confirmed that it was the responsibility of night shift CNAs to check and clean wheelchairs, but the resident’s wheelchair remained unclean over several days. Further review revealed that the facility did not have any policies or in-service training related to environmental or wheelchair cleaning. Multiple staff members, including CNAs, LPNs, and the DON, acknowledged that cleaning wheelchairs was part of the night shift CNAs’ duties, but the lack of a formal policy or training contributed to the ongoing issue. The deficiency was identified through direct observation, resident and staff interviews, and review of facility records.
Failure to Post Complete Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the required daily nurse staffing information as mandated. Observations on two consecutive days revealed that while the facility posted staff assignments and the number of licensed staff by category (RN, LPN, CNA), they did not consistently post the facility census or the actual hours worked by licensed personnel. On one day, the census was missing, and on the next, although the census was posted, the actual hours worked were still not displayed. Interviews with the Director of Nursing and the Administrator confirmed that the posted information was intended to show staff assignments and numbers, but did not include all required elements such as actual hours worked.
Inaccurate MDS Assessment for Hospice Resident
Penalty
Summary
The facility failed to ensure the accuracy and completeness of the Minimum Data Set (MDS) for a resident, which is essential for planning and providing necessary care and services. The resident was admitted with a diagnosis of Moderate Protein-Calorie Malnutrition and had elected hospice services. However, the significant change MDS assessment inaccurately marked section J1400 as 'No,' indicating the resident did not have a prognosis of less than six months to live, despite being on hospice care. This error was identified during a review of the MDS with the MDS Coordinator, who acknowledged the mistake and confirmed that section J1400 should have been marked 'Yes' to reflect the resident's hospice status and prognosis.
Failure to Include Oxygen Therapy in Resident's Care Plan
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was developed and implemented for a resident who was admitted with diagnoses of respiratory failure and sleep apnea. The resident had a physician's order for oxygen at two liters per minute as needed, which was documented in the Order Summary Report. However, the care plan dated October 21, 2024, did not reflect that the resident received oxygen as needed, despite the Minimum Data Set (MDS) indicating that the resident was receiving oxygen while in the facility. Interviews with the MDS Coordinator and the Director of Nursing confirmed that they were aware of the physician's order for oxygen and that the MDS indicated the resident received oxygen. Both acknowledged that the care plan should have included this information but did not. The facility's policy on comprehensive, person-centered care plans requires that they include measurable objectives and timeframes and describe the services to be furnished to meet the resident's needs, which was not adhered to in this case.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure proper food storage and sanitation practices in the kitchen and pantry areas. Observations revealed that food items in the refrigerator and freezer were not covered or sealed, including Parmesan cheese, sausage patties, chicken, cobbler crust dough sheets, dinner dough, egg rolls, broccoli, leftover spaghetti, and mixed vegetables. Additionally, the temperature of the upright refrigerator was found to be 51.8 degrees Fahrenheit, which is above the recommended storage temperature. Expired food items, such as vanilla med pass 2.0, were also found in the pantry and medication rooms, and the ice machines in various locations had wet sage-colored residues, indicating inadequate cleaning practices. The kitchen environment was unsanitary, with peeling paint, rust, dirt, and lint accumulation on walls, air vents, and light fixtures. The floor in the storage room had stains, and the baseboard was loose, exposing the cement underneath. Staff members were observed not following proper hand hygiene and glove use protocols, such as not washing hands before handling clean equipment or food items, and contaminating gloves before food preparation. These deficiencies had the potential to affect 108 residents who received food from the kitchen.
Failure to Maintain Resident Privacy and Dignity
Penalty
Summary
The facility failed to maintain privacy and dignity for two residents. Resident #9, who had a history of urinary tract infection, overactive bladder, retention of urine, and acute cystitis, was observed with her blanket pulled back and incontinence brief detached without the privacy curtain being pulled. This exposed the resident to her roommate and anyone entering the room. The CNA involved acknowledged that the privacy curtain should have been pulled before providing care. Resident #13, diagnosed with paraplegia and quadriplegia, was observed being transported on a shower bed down the hall wearing only a hospital gown, without any covering. The CNAs involved admitted they were aware the resident should have been covered but cited reasons such as lack of available blankets and time constraints. The Director of Nursing confirmed that residents should be covered during transport to maintain privacy and dignity. The facility's policy on Resident Rights mandates that all residents be treated with kindness, respect, and dignity, including the right to privacy and confidentiality.
Inaccurate Comprehensive Assessments for Two Residents
Penalty
Summary
The facility failed to accurately assess the comprehensive assessment for two residents, leading to deficiencies in their care plans. Resident #52, diagnosed with bipolar disorder, depression, and anxiety disorder, was documented as having severe cognitive impairment on the Brief Interview of Mental Status (BIMS). However, the Minimum Data Set (MDS) Coordinator was unaware that Resident #52 was considered by the state as PASSAR level II, and this information was not reflected in the electronic records. The Director of Nursing (DON) confirmed that the comprehensive assessment did not accurately reflect Resident #52's PASSAR level II status. Resident #90, diagnosed with depression, old myocardial infarction, and chronic obstructive pulmonary disease (COPD), was documented as a smoker in the Smoking Safety Screen and care plan. However, the Significant Change Minimum Data Set (MDS) did not indicate that Resident #90 was a smoker. The MDS Coordinator confirmed that this information was not coded correctly in the comprehensive assessment. The DON also confirmed the inaccuracy, and the facility did not provide the surveyor with an MDS coding policy or the relevant section of the Resident Assessment Instrument manual used for coding.
Failure to Maintain Resident Hygiene
Penalty
Summary
The facility failed to ensure that Resident #104 received proper care for activities of daily living, specifically in maintaining clean nails and providing regular shaves. Resident #104, who has a diagnosis of a Stage 4 Pressure Ulcer in the sacral region and severe cognitive impairment, required substantial assistance with bathing. Despite this, observations on multiple occasions revealed that the resident's nails had a black substance underneath, and his beard was approximately 2 inches long. The resident confirmed that he had not been shaved since his admission and that staff did not clean his nails. Facility policies dated 05/08/2024 for shaving and nail care were reviewed, indicating the importance of cleanliness and infection prevention. However, interviews with staff, including a Certified Nurse Aid (CNA) and the Director of Nursing (DON), confirmed that the resident's nails and beard were not being maintained as per the care plan, which specified nail cleaning and shaving on Tuesdays, Thursdays, and Saturdays. The CNA acknowledged the need for nail cleaning and shaving, and the DON confirmed the expected frequency of these tasks, highlighting a clear lapse in the execution of the resident's care plan.
Failure to Ensure Hydration Availability
Penalty
Summary
The facility failed to ensure hydration was available at all times for Resident #69, who had a diagnosis of constipation and was cognitively intact with a BIMS score of 15. On 5/05/24 at 11:58 AM, Resident #69 informed the surveyor that they had not had any water all day and often lacked water on weekends. At 12:30 PM and 1:40 PM on the same day, it was observed that Resident #69 still did not have water available. Certified Nurse Aide #11 admitted that she had not had a chance to pass water that day due to being busy, although she usually did so twice a day. The Director of Nursing confirmed that residents should have water available at all times.
Failure to Provide Clean and Properly Stored Oxygen Tubing
Penalty
Summary
The facility failed to provide clean oxygen tubing and proper storage for oxygen tubing for two residents on oxygen therapy. On multiple occasions, a surveyor observed oxygen tubing lying on the floor in Resident #32's room. When questioned, a CNA stated that the appropriate action would be to notify the nurse, and the DON confirmed that the tubing should be immediately replaced if found on the floor. Additionally, the facility's oxygen administration policy was provided by the DON. For Resident #97, who had a diagnosis of Moderate Persistent Asthma and a severe cognitive impairment as indicated by a BIMs score of 00, the surveyor observed the oxygen tubing not being stored in a storage bag when not in use. The tubing was found on top of the oxygen machine on multiple occasions. Both RN #1 and the DON confirmed that the tubing should be stored in a storage bag when not in use. These observations indicate a failure to adhere to proper respiratory care protocols for residents on oxygen therapy.
Failure to Conduct Side Rail Assessment for Resident
Penalty
Summary
The facility failed to ensure bed rails were not used for Resident #104 without a side rail assessment to prevent potential accidents. Resident #104, who had a diagnosis of Pressure Ulcer Sacral Region Stage 4, was observed with bed rails up on multiple occasions. The Medicare-5 Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/08/24 did not indicate that Resident #104 used side rails, and a side rail assessment dated [DATE] also indicated no use of bed rails. Despite this, Resident #104 was observed with bed rails up on 5/05/24, 5/06/24, and 5/07/24. Certified Nurse Aide (CNA) #11 confirmed that Resident #104 had been using side rails since admission. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed the use of side rails without a proper assessment. The facility's policy titled 'Bed Safety' requires an interdisciplinary assessment, consultation with the attending physician, and input from the resident or legal representative if side rails are used.
Failure to Implement Gradual Dose Reduction for Antidepressant Medication
Penalty
Summary
The facility failed to implement a gradual dose reduction for a resident diagnosed with Major Depressive Disorder. Despite a physician's recommendation to reduce the resident's Sertraline dosage from 125 milligrams to 100 milligrams daily, the reduction was not carried out. The Director of Nursing (DON) signed the recommendation, but the resident continued to receive the original dosage of 125 milligrams as documented in the Medication Administration Records for April and May 2024. Both the Licensed Practical Nurse (LPN) and the DON confirmed that the resident was still receiving the higher dosage, and the DON was unable to explain why the physician's order was not implemented. The deficiency was identified during a review of the resident's records and interviews with the facility staff. The resident, who scored 13 on the Brief Interview for Mental Status (BIMs), indicating cognitive intactness, had been on Sertraline since June 2023. The failure to reduce the dosage as recommended by the physician highlights a lapse in the facility's medication management and order implementation processes. The DON acknowledged the oversight but did not provide a reason for the failure to update the medication order in the system.
Failure to Serve Meals According to Planned Menu
Penalty
Summary
The facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents. Specifically, for two observed meals, the facility did not provide the correct portions of pork chili Verde and blackened chicken breast to residents on mechanical soft diets. On 05/07/24, the menu indicated that residents on mechanical soft diets should receive 3/4 cup of pork chili Verde. However, the dietary employee used a 6-ounce spoon to prepare the servings, and only 7 servings were prepared instead of the required amount. Additionally, the dietary supervisor confirmed that they ran out of mechanical soft meat during the lunch meal, and the dietary employee could not recall the exact portion sizes served to each resident. On 05/08/24, the menu indicated that residents on mechanical soft diets should receive 4 ounces of blackened chicken breast. However, the dietary employee used a 2-ounce spoon to serve the chicken, providing only one serving to each resident. These actions resulted in the residents not receiving the appropriate portions as per the planned menu, potentially affecting the nutritional intake of 27 residents on mechanical soft diets and 7 residents on pureed diets.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to ensure an effective pest control program was maintained to keep the facility free of pests. During an observation on 05/07/24 at 10:50 AM, multiple flies were seen in various areas of the kitchen during meal preparation and serving. Specifically, flies were observed on a cart by the food preparation sink, on the wall near the dishwashing machine, by the plate warmer, and flying around the food preparation area. Further observations at 11:26 AM and 11:53 AM revealed additional flies on clean dish racks, a box of iodized salt, a window by the food preparation counter, a menu, a microwave, and a refrigerator. The Dietary Supervisor confirmed the presence of flies and noted that the issue had recently started due to warmer weather and flies being outside the back door. The facility's pest control records indicated that monthly pest control services were performed, but flies were not reported in the documentation. The records from 02/22/24, 02/26/24, 03/21/24, and 04/22/24 showed that the pest control service focused on roach activity and exterior bait stations, with no mention of flies. Despite the regular pest control services, the facility did not effectively address the fly infestation in the kitchen, leading to the observed deficiency.
Failure to Ensure Call Lights Within Reach
Penalty
Summary
The facility failed to ensure that call lights were within reach for four out of five residents reviewed for call light accessibility. Observations by the surveyor revealed that multiple residents, including those with severe cognitive impairments and incontinence issues, did not have their call lights within reach. For instance, one resident with a history of repeated falls and severe cognitive impairment was observed multiple times with the call light on the floor, out of reach, despite being awake and in bed. Another resident, who was cognitively intact, expressed frustration over the call light being on the floor and not being answered promptly. Interviews with CNAs and the Director of Nursing confirmed the importance of ensuring call lights are within reach to prevent risks such as falls, dehydration, and skin breakdown. Despite this understanding, the surveyor's observations indicated a consistent failure to adhere to this practice, as evidenced by the repeated instances of call lights being inaccessible to residents. This deficiency highlights a significant lapse in the facility's responsibility to accommodate the needs and preferences of its residents, particularly in ensuring their ability to call for assistance when needed.
Failure to Complete Self-Administration Safety Screen
Penalty
Summary
The facility failed to complete a self-administration safety screen for a resident (Resident #27) to ensure that the resident could safely administer medication. The resident had several diagnoses, including hypertension, chronic kidney disease stage 4, old myocardial infarction, chronic obstructive pulmonary disease, atrial fibrillation, and benign prostatic hyperplasia with lower urinary tract symptoms. Despite these conditions, the resident had multiple over-the-counter medications on their nightstand, including allergy relief medication, lidocaine gel, and antifungal powder, which were not documented in the physician's orders. The resident also had an antacid and cold and flu syrup in the nightstand, which were confirmed by an LPN. The resident's care plan indicated that medications should be administered in accordance with the physician's orders and the resident's ability to safely take them, but no self-administration assessment had been completed until after the surveyor's observations. The surveyor observed the medications on the resident's nightstand multiple times over several days, indicating that the medications were consistently accessible to the resident without proper assessment. The Director of Nursing confirmed that a self-administration assessment was only completed after the surveyor's observations. The facility's policy on self-administration of medications states that residents have the right to self-administer medications if the interdisciplinary team has determined it is clinically appropriate and safe, which was not adhered to in this case.
Failure to Update Care Plan for Indwelling Catheter
Penalty
Summary
The facility failed to ensure that the care plan for a resident was revised to reflect the presence of an indwelling catheter. The resident had a history of urinary tract infection, overactive bladder, retention of urine, and acute cystitis. The physician's order indicated the use of a 16 French indwelling urinary catheter with a 10 cubic centimeter balloon. The Minimum Data Set (MDS) assessment confirmed the resident had an indwelling catheter and was always incontinent of bowel. Despite this, the care plan, last revised on 4/30/24, did not accurately reflect the presence of the indwelling catheter, although it included interventions related to catheter care initiated on 04/04/2024. On 05/08/24, the Minimum Data Set Coordinator and the Director of Nursing confirmed that the care plan was not updated to reflect the resident's current condition. The facility's policy on comprehensive person-centered care planning states that assessments are ongoing and care plans should be revised as the resident's condition changes. This failure to update the care plan was identified during observations, interviews, and record reviews conducted by the surveyors.
Improper Incontinence and Catheter Care
Penalty
Summary
The facility failed to ensure proper incontinence care for a resident with an indwelling urinary catheter, leading to potential risks of dislodging and trauma. Resident #9, who had a history of urinary tract infections and other related conditions, was observed receiving improper peri care from CNA #8. The CNA wiped stool downward, which is incorrect, and did not ensure the catheter was positioned to prevent pulling and strain. Additionally, there was no stat lock in place to secure the catheter, increasing the risk of dislodging and trauma. The Director of Nursing confirmed that peri care should be performed correctly and that the catheter should be disconnected from the bed to prevent pulling. The facility's policy on urinary incontinence did not address the specific deficient practice observed. This failure in care had the potential to affect other residents with indwelling catheters in the same hall.
Latest citations in Arkansas
A resident with peripheral vascular disease, prior toe amputation, and malnutrition had multiple lower extremity wounds managed by an external Wound Care Clinic, which issued detailed written orders for cleansing, specific dressings, and compression. Facility TAR entries showed generalized leg treatments on a fixed schedule instead of the ordered every-other-day frequency, did not distinguish between multiple wounds on the same leg, omitted documentation of ordered transfer foam and a compression stocking, and added self-adherent wrap that was not ordered. Interviews with the TN and DON confirmed that the TN was responsible for entering and carrying out clinic orders, and leadership could not produce documentation that all ordered treatments were provided or explain the altered treatment frequency, contrary to facility policy requiring treatments to follow provider orders.
Surveyors found that a nurse responsible for wound care and infection prevention failed to follow basic infection control practices while treating two residents with pressure ulcers and one with a suprapubic catheter. The nurse repeatedly handled keys, a phone, and a computer, then accessed and prepared wound supplies without performing hand hygiene, touched gauze with ungloved hands before using it on a wound, and set up supplies on non‑impervious paper towels next to personal items instead of on a properly disinfected, protected surface. During one observation, the nurse cleaned a hip pressure ulcer and then a suprapubic catheter site using separate gauze cups but without changing gloves or performing hand hygiene between dirty and clean tasks, and then applied dressings after glove removal without washing hands. Facility policies required clean technique, use of an impervious barrier, handwashing between dirty and clean steps, and labeling dressings, but these were not followed, and the nurse and leadership acknowledged that the nurse had not received formal wound care training from the facility.
Two residents with complex medical conditions and extensive medication regimens experienced significant medication errors when new LPNs, inadequately oriented and not fully competency-checked, misadministered drugs during med pass. In one case, a new LPN on her first day, unfamiliar with residents and the electronic system, gave another resident’s medications—including a hypoglycemic and an antihypertensive—to a cognitively intact resident with multiple cardiopulmonary and renal diagnoses, leading to hypotension, hypoglycemia, and hospital transfer. In the other case, an LPN in training and her preceptor pulled medications simultaneously from the same cart, and a resident requesting pain medication received an excessive dose of a controlled sleeping pill instead, a drug the pharmacist stated would definitely increase sedation and could depress CNS and breathing. Facility policy required verification of resident identity, triple-checking medication labels, and at least three days of accompanied med rounds for new personnel, but interviews showed these requirements were not fully implemented before the new nurses participated in or conducted medication administration alone or in a hurried, shared-cart process.
The facility failed to implement and complete its nurse orientation and competency validation process for new LPNs, resulting in two separate medication errors. One LPN, new to LTC and unfamiliar with the facility’s computer system, was left alone on the med cart after only partial observation-based training and without a completed competency checklist, and a resident received another resident’s medications. Another new LPN, also without documented competency sign-offs, was in joint med-pass with an untrained preceptor when a resident requesting pain medication was given sleeping pills after the preceptor pulled the wrong controlled medication and the trainee administered it. Preceptors were selected informally from floor nurses without preceptor training, and leadership interviews confirmed that required competency checklists and the facility’s own med-pass orientation policy were not consistently followed or documented.
Two residents who required substantial/maximal assistance with ADLs did not receive consistent nail care, use of protective geri-sleeves, and shaving as outlined in their care plans. One resident with Parkinson’s disease, severe cognitive impairment, and a history of arm skin tears was repeatedly observed with overgrown fingernails and exposed arms without geri-sleeves, despite ADL records indicating weekly nail checks and encouragement of geri-sleeves. Staff interviews revealed uncertainty about who was responsible for applying geri-sleeves and providing nail care, and ADL documentation lacked staff initials. Another resident with tremors and moderate cognitive impairment was observed multiple times with visible chin hair and reported not being offered shaving, even though ADL records showed facial hair checks and shaving as needed were documented as completed without initials. A CNA acknowledged seeing the facial hair earlier and intending to shave the resident later, and the DON confirmed CNAs were responsible for checking and removing facial hair and that documentation should not indicate tasks were done when they were not.
A resident with respiratory failure, heart failure, type 2 diabetes, and COPD was approved to self-administer inhaled medications, but surveyors observed the resident’s corticosteroid and beta2-agonist inhalers left unattended on the over-bed table on multiple occasions, and a medication lockbox kept on the over-bed table with the key left in the lock. The resident reported being told they could use their own inhalers. An LPN stated the resident was approved for unsupervised self-administration but admitted not being familiar with the self-administration policy, while also acknowledging that medications should not be left on the over-bed table and that the lockbox should not have the key in it. The DON and another LPN described that the facility’s process and expectations required assessment of the resident’s ability to self-administer, demonstration of correct use, and secure locked storage out of reach of other residents, and CNAs stated that medications should not be left out in resident rooms.
A resident with terminal Parkinson’s disease and severe cognitive impairment was enrolled in hospice, with hospice aides providing baths and an updated care plan specifying hospice CNA, RN, social services, and chaplain visits. However, no hospice physician order was present in the EHR at the time, no hospice notes appeared in progress notes, and the MDS still reflected that the resident was not on hospice. The MDS Coordinator reported she did not complete a Significant Change in Status Assessment because there was no hospice order in the system to trigger it, later finding that the hospice admission order had been dated earlier but not entered until much later. The DON stated that the nurse on duty at hospice admission should have entered the hospice order and believed nurses knew they were responsible for doing so.
A nonverbal resident with a history of brain stem hemorrhage and intact cognition was admitted with documented unclear speech, rare ability to make themself understood, and reliance on nodding, head shaking, and sign language for communication, yet no communication deficit with individualized interventions was initiated on the comprehensive care plan. Multiple assessments and progress notes by nursing, social services, APRN, and SLP consistently described the resident as nonverbal and using alternative communication methods, but these findings were not incorporated into a person-centered care plan. CNAs, an RNA, and an LPN reported using yes/no questions, body language, facial cues, and the resident’s hand signals to communicate, while also stating they did not know sign language and had not seen communication boards or structured tools, and leadership acknowledged that a communication deficit should have been care planned and that there were no facility policies guiding communication care planning for nonverbal residents.
A resident with neuropathy, non‑weight‑bearing status on one leg, multiple comorbidities, and a known history of falls was care planned as high fall risk and required two‑person assistance with a gait belt for all transfers. After prior incidents where the resident’s legs had given out during transfers, two staff attempted a wheelchair‑to‑toilet transfer by standing and pivoting the resident using the stronger leg while the resident held grab bars, but they did so without a gait belt. The resident’s legs collapsed, the resident went down to the knees, and an abrasion to the knee occurred. Staff and leadership interviews, along with policies and job descriptions, confirmed that a gait belt was required for all assisted transfers and that staff were expected to follow this procedure, but the involved staff admitted they forgot to use the gait belt during this transfer.
A resident with respiratory failure and other comorbidities received O2 via nasal cannula under an order that lacked a start date and was not set up as a scheduled order in the electronic record, even though oxygen use was documented on multiple days. Over several days, the resident’s humidifier bottle was repeatedly observed to be undated or dated but empty while the resident was on 2 L O2, and the resident reported persistent nasal dryness and that the bottle had been empty despite asking staff to change it. An LPN confirmed the order issue and acknowledged the empty, dated humidifier bottle, and leadership reported expectations for changing tubing and humidifier bottles but had no policy addressing oxygen equipment or humidified water.
Failure to Follow Wound Clinic Orders for Lower Extremity Wounds
Penalty
Summary
The deficiency involves the facility’s failure to complete and follow wound care provider orders for one resident with multiple lower extremity wounds. The resident was admitted with diagnoses including peripheral vascular disease, acquired absence of a right toe, and malnutrition, and was documented as alert, oriented, and cognitively intact. The resident received wound care at an external Wound Care Clinic, which issued detailed written orders on two separate dates for multiple wounds on both lower legs, specifying cleansing with normal saline, use of transfer foam or autolytic debridement gel, specific secondary dressings, soft cloth surgical tape, sterile roll gauze, gauze sponges, and, for one right lower leg wound, a compression stocking. Review of the facility’s Treatment Administration Record (TAR) for the same period showed that the treatments documented did not match the clinic’s orders. The TAR listed generalized treatments for the left and right lower legs, including cleansing with normal saline, gauze to the wound bed, and application of self-adherent wrap from toes to bend of leg on a Tuesday, Thursday, Saturday schedule, rather than every other day as ordered. Later TAR entries for bilateral extremities referenced autolytic debridement gel, auto debridement dressing, and elasticated tubular bandage, but still did not clearly distinguish between the multiple wounds on the right lower leg or document all ordered components. There was no distinction on the TAR to ensure both right lower leg wounds were treated, no documentation that transfer foam was applied as ordered, and no documentation that the ordered compression stocking was applied to the specified right lower leg wound. Interviews and record review confirmed these discrepancies and the lack of supporting documentation. The Treatment Nurse described a process in which Wound Care Clinic orders were faxed to the facility, compiled, and then entered onto the TAR by the Treatment Nurse after leadership meetings or by the end of the business day. The DON stated that it was the Treatment Nurse’s responsibility to ensure clinic orders were completed and acknowledged that wounds could deteriorate if not treated per provider orders. During a joint interview, the DON, Administrator, and Nurse Consultant were unable to provide any documentation that the transfer foam treatment was given as ordered or any explanation for why every-other-day orders were carried out on a fixed Tuesday, Thursday, Saturday schedule. Facility policy on Medication and Treatment Orders required that medications be administered per the written order of a licensed provider, which was not followed in this case.
Inadequate Hand Hygiene and Aseptic Technique During Wound and Catheter Care
Penalty
Summary
The deficiency involves the facility’s failure to provide wound care in a manner that prevented infection for two residents receiving wound treatments. For the first resident, who had cellulitis, type 2 diabetes mellitus, protein-calorie malnutrition, venous insufficiency of both lower extremities, chronic venous hypertension with inflammation, candidiasis of the skin and nails, and a stage 2 pressure ulcer to the sacrum, the Treatment Nurse (TN), who was also the Infection Preventionist (IP), did not consistently perform hand hygiene or maintain a clean field. During wound care, the TN handled personal items such as keys, a cell phone, and the computer, then accessed wound care supplies from the treatment cart without performing hand hygiene afterward. The TN touched gauze pads with ungloved hands, sprayed them with wound cleanser, and later used those same gauze pads to cleanse the resident’s wound. The TN also set up supplies on a bathroom counter using a non‑impervious paper towel as a barrier, contrary to facility policy requiring an impervious barrier, and did not date or initial the new dressing. For the second resident, who had diagnoses including congestive heart failure, protein-calorie malnutrition, hypertension, GERD, neuromuscular bladder dysfunction, a stage 3 pressure ulcer of the right hip, urethrocutaneous fistula, UTI, and an indwelling catheter, the TN again failed to follow infection prevention practices during wound care. The TN unlocked the treatment cart with keys from her pocket, returned the keys to her pocket, and touched the computer before retrieving wound care supplies, then proceeded without performing hand hygiene until later in the process. She prepared gauze pads in cups with wound cleanser while gloved, then removed her gloves and continued the setup. In the resident’s room, she cleaned only half of the bedside table with a wet, soapy paper towel and dried it with another towel, then placed a non‑impervious paper towel as a barrier for wound supplies, while the other half of the table remained cluttered with personal items including a basin with cups and straws hanging over the wound supplies. During the wound care for the second resident, the TN washed her hands in the bathroom for approximately six seconds before donning gloves. She removed the old dressing from the right hip pressure ulcer, changed gloves, and then used gauze from one cup to clean the hip pressure ulcer. Without performing hand hygiene or changing gloves between dirty and clean tasks, she then used gauze from a second cup to clean the resident’s suprapubic catheter site, which she stated had drainage and had been cauterized the previous week. After removing her gloves, she did not perform hand hygiene before placing a split drain gauze around the suprapubic catheter and applying calcium alginate and a bordered foam dressing to the right hip wound. The TN later acknowledged that she did not wash her hands when going from dirty to clean tasks, that she should have changed gloves before moving to the secondary dressing, and that she had not received wound care training from the facility despite functioning as the wound care nurse and IP. Facility policies required clean technique, prevention of supply and surface contamination, use of an impervious barrier, handwashing after removing dirty gloves and before donning clean gloves, and labeling new dressings with initials, date, and time, as well as adherence to handwashing guidelines consistent with CDC recommendations for at least 15 seconds of rubbing. Interviews with the TN, Nurse Practitioner (NP), and Director of Nursing (DON) further clarified the expectations and deviations from practice. The TN stated she believed she performed hand hygiene when entering rooms and after touching anything dirty, but acknowledged she did not wash her hands between dirty and clean tasks and recognized that setting up wound supplies next to personal items would be an infection control issue. The NP stated that the suprapubic catheter and pressure ulcer should be cleaned one at a time and not treated simultaneously, and that she would not want wound contaminants introduced to the suprapubic catheter. The DON reported that the TN had been performing wound care since around November, had no wound care certification, and had received no specific wound care training from the facility, although the DON believed the TN had prior wound care experience elsewhere. The DON stated that staff should clean hands and change gloves when going from dirty to clean tasks, that separate areas such as a suprapubic catheter and a pressure ulcer should not be treated at the same time due to infection concerns, that dressings should be dated as a standard practice, that bedside tables should be clean, uncluttered, and disinfected rather than just washed with soap and water, and that a brief six‑second handwash was not appropriate.
Failure to Prevent Significant Medication Errors for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to prevent significant medication errors for two residents during medication administration. For the first resident, who had multiple complex diagnoses including pneumonia, COPD, CHF, atrial fibrillation, pulmonary hypertension, peripheral vascular disease, chronic kidney disease stage 3, hypertension, hyperlipidemia, and aortic valve stenosis, a nurse on her first day at the facility administered another resident’s medications in error. The resident was cognitively intact and receiving numerous scheduled medications, including diuretics, anticoagulants, antihypertensives, electrolyte replacements, and oxygen. A Medication Error Report documented that the resident was mistakenly given four incorrect medications intended for another resident, including a blood sugar–lowering medication, an antidepressant, a uric acid–lowering medication, and an antihypertensive with side effects of hypotension and hyperkalemia and label warnings related to diabetic medications. The error for the first resident occurred when an LPN, new to LTC and to the facility’s computer system, misidentified the resident and pulled the wrong medications. The LPN reported that it was her first day, she had limited orientation time with an RN preceptor that morning, and she had not been checked off as competent to administer medications independently. She stated she did not yet know the residents, found the electronic photos too small to distinguish individuals, and did not know how to enter orders into the computer. She described feeling overstimulated and attempting to work independently. The UM, who was simultaneously functioning as wound nurse, UM, and preceptor, left the LPN alone on the cart after the LPN stated she felt comfortable, despite the UM not having observed her passing medications and not having completed the medication portion of the competency checklist. The RN who precepted earlier in the day stated the LPN had only observed her, had not performed tasks independently, and had not been checked off to administer medications alone. Following the wrong-medication administration to the first resident, vital signs later showed hypotension and hypoglycemia, and the resident was sent to the hospital. Hospital records documented treatment for a medication error, hypotension, hypoglycemia, elevated heart enzymes, and acute kidney injury, with very low blood pressure on arrival and the resident reporting feeling like they were dying. Documentation from the hospital indicated facility staff reported the resident had been hypotensive for two hours. The pharmacist, after reviewing the resident’s scheduled medications and the medications given in error, stated she would have monitored for low blood pressure, low blood sugar, and oversedation, and identified multiple medications that could contribute to these effects. The NP stated it was difficult to determine whether the medication error caused the event, noting the resident’s existing pneumonia and kidney function issues. The resident’s representative reported being notified of a severe drop in blood pressure and stated that a physician advised seeking legal advice. The second resident involved in the deficiency had multiple diagnoses including critical illness myopathy, metabolic encephalopathy, cerebral edema, diabetes, morbid obesity, respiratory failure with hypoxia and hypercapnia, obstructive sleep apnea, cognitive communication deficit, dysphagia, hyperlipidemia, bipolar disorder, hypertension, and chronic kidney disease, and was cognitively intact. This resident was on a complex medication regimen including antipsychotics, antidepressants, anticoagulants, antibiotics, diuretics, opioids, and hypoglycemics. A Medication Error Report documented that the resident was accidentally given two sleeping pills instead of two pain pills. The error occurred while an LPN in training and her preceptor were both pulling medications from the same cart, with the trainee pulling non-controlled medications and the preceptor pulling narcotics. For the second resident, the trainee LPN reported that the resident had requested a pain pill but was given sleeping pills instead. She stated that the mistake was discovered later when controlled medications were counted and that the sleeping pill, a controlled medication, was stored in the narcotic box with other controlled medications. She reported that the preceptor punched the medication from the wrong card, that the pills were both small white tablets, and that they were trying to hurry. The trainee LPN stated she did not recall any specific competency check-offs and that her license had simply been verified. The pharmacist stated that the dose of sleeping medication given exceeded the recommended daily dose and would definitely increase sedation, with potential for amnesia, CNS depression, and breathing interruptions if the resident did not use a pressurized mask while sleeping, as well as possible sleepwalking episodes. The NP later reported there were no adverse side effects observed in this resident. The facility’s written Medication Administration policy required that medications be administered in accordance with orders, that the individual administering medications verify resident identity before administration, and that the label be checked three times to ensure the right resident, medication, dose, and route. The policy also stated that medications ordered for one resident may not be administered to another, and that new personnel authorized to administer medications would not be permitted to prepare or administer medications until oriented to the facility’s medication administration system. It further required that a charge nurse accompany new nursing personnel on medication rounds for a minimum of three days to ensure procedures were followed and proper resident identification methods were learned. Interviews with the UM, RN preceptor, and LPNs indicated that the new nurses involved in both medication errors were allowed to participate in or conduct medication passes without full completion of competency checklists, without consistent direct observation, and while preceptors were performing multiple roles or sharing the cart, contributing to the misadministration of medications to both residents.
Failure to Implement Effective Nurse Orientation and Competency Validation Leading to Medication Errors
Penalty
Summary
The deficiency involves the facility’s failure to implement an effective nurse training and competency program for new LPN staff, resulting in incomplete orientation and unverified competencies for at least two nurses. The facility maintained a New Trainee Folder and a Licensed Nurse Competency Skills Check-off form intended to cover unit safety, communication, infection control, nursing care, emergency procedures, equipment, medication administration, pain management, resident rights, abuse, dementia care, QAPI, person-centered care, cultural competency, and HIPAA. Human Resources reported that the competency checklist was to be printed and placed in a staffing binder, completed by the preceptor over the first three days, and then signed off by leadership. However, for both reviewed LPNs, these competency checklists were not completed, and there was no documented verification that they had met medication administration or other required competencies before functioning independently. One LPN, on her first day working in the facility and with no prior LTC experience, was involved in a medication error in which a resident received another resident’s medications. This LPN reported that she had only been trained by an RN from 6 AM to 10 AM on how residents took their medications and who had swallowing issues, and that she did not know how to enter orders into the computer system and was unfamiliar with the software. The RN preceptor stated that the LPN had only observed her and had not performed any tasks independently before the RN left, and that she had not checked the LPN off to administer medications alone. The Unit Manager acknowledged that the LPN had no LTC experience, that she did not complete the medication portion of the competency checklist, and that she left the LPN alone on the cart after the LPN stated she felt comfortable, despite not having seen her pass medications. The facility’s Medication Administration policy required that new personnel not administer medications until oriented to the system and that a charge nurse accompany them on medication rounds for a minimum of three days, but this process was not followed or documented for this LPN. Another new LPN, also without a completed competency checklist, was involved in a separate medication error in which a resident requesting pain medication received sleeping pills instead. This LPN reported that she was in training with a preceptor, and that both nurses were pulling medications from the same cart, with the preceptor handling controlled substances. The error occurred when the preceptor punched a sleeping pill from the wrong card, and the trainee LPN administered it, noting that the pills were both small and white and that they were trying to hurry. The LPN stated she did not recall any specific competency check-offs being done beyond a license check. The Unit Manager and ADON both confirmed that preceptors were simply floor nurses who had been at the facility longer, with no formal preceptor training, and that the current training program had only recently started. Employee files for both LPNs lacked completed Licensed Nurse Competency Skills Check-off forms as of the survey date, and leadership interviews showed uncertainty about when competency checklists should be completed and how much training the LPNs had actually received before being allowed to function independently.
Failure to Provide Regular Nail Care, Protective Sleeves, and Shaving for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide regular nail care and use of protective geri-sleeves for one resident and shaving/personal grooming for another resident, as required by their care plans and ADL needs. For Resident #91, surveyors observed on multiple occasions that the resident’s fingernails extended over the tips of the fingers, despite a care plan intervention directing staff to check nail length and trim and clean nails on bath day and as necessary. The resident had Parkinson’s disease with dyskinesia, severe cognitive impairment (BIMS score of 04), required substantial/maximal assistance with showering and personal hygiene, and had a history of skin tears on the right arm. The care plan also included an intervention to encourage use of geri-sleeves due to potential skin integrity impairment, but the resident was repeatedly observed with arms exposed and without geri-sleeves in place. Record review for Resident #91 showed ADL tasks for checking, cutting, and filing nails weekly, and for encouraging geri-sleeves as tolerated, were marked as completed on several dates; however, there were no staff initials to identify who performed these tasks. During interviews, CNAs and a MA-C demonstrated uncertainty about who was responsible for placing geri-sleeves on the resident, when they should be applied, and whether the resident was supposed to wear them at all. One CNA believed hospice aides provided nail care and that they visited three times a week, while another CNA stated she provided nail care when needed and that the resident did not wear geri-sleeves, even though she acknowledged the resident would need them due to fragile skin. The DON reported there was no facility policy for ADLs and did not provide skills check-offs for the CNAs involved. For Resident #107, surveyors twice observed visible hair on the resident’s chin, and the resident reported that staff had not offered to shave the chin. The resident had a diagnosis of other specified forms of tremors, moderate cognitive impairment (BIMS score of 09), and required substantial/maximal assistance with showering and personal hygiene. The care plan required staff assistance with bathing/showering and personal hygiene, and the ADL task list showed scheduled bath days and documented completion of a task to check for facial hair and shave as needed on several dates, again without staff initials. Progress notes did not show any refusal of shaving by the resident. A CNA stated she determined needed care by looking in the resident’s closet care plan, that CNAs were responsible for bathing/showering, and that staff checked for facial hair on shower days and should check daily. She acknowledged seeing facial hair that morning and intended to shave the resident later. The DON stated CNAs were responsible for checking and removing facial hair during showers and as needed, and that CNAs should not document facial hair removal when it had not been done.
Failure to Safely Manage Self-Administration of Inhalers and Medication Storage
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident approved for self-administration of medications could follow instructions so that medications were not left at the bedside. The resident had diagnoses including respiratory failure, heart failure, type 2 diabetes, and COPD, and was receiving oxygen via concentrator. Record review showed orders for a beta2-agonist inhaler and a corticosteroid inhaler, but no physician order for self-administration rights was initially found. The facility’s policy required that residents who self-administer be assessed by the IDT to ensure they could safely administer and store medications out of reach of other residents. On multiple observations, surveyors found the resident’s inhalers and lockbox not secured as required. During one observation, the resident was resting in bed with eyes closed, the oxygen concentrator running at two liters via nasal cannula, but the nasal cannula was not in place, and both the corticosteroid and beta2-agonist inhalers were left unsupervised on the over-bed table. The resident stated they had been told they could use their own inhalers. On a later observation, a lockbox with the key left in the lock was seen on the over-bed table, and the resident stated the lockbox contained prescription inhalers but could not recall when it was provided. On another observation, the lockbox with the key still in the lock remained on the over-bed table while the resident was resting with oxygen in place. Interviews with staff confirmed that the resident had been approved for self-administration but revealed gaps in adherence to policy and lack of staff familiarity with self-administration procedures. An LPN stated the resident had been approved to self-administer inhalers at the bedside unsupervised and acknowledged not being familiar with the self-administration policy, while also stating that medications should not be left unattended on the over-bed table and that the lockbox should not have the key in the lock. The DON described the process for approving self-administration, including assessment, demonstration of use, and locked storage, and stated it would not be appropriate to leave a key in the lock or medications out on the over-bed table. Another LPN reported there had not been prior residents with self-administration rights and agreed that medications should not be stored on the over-bed table or in a lockbox with the key in place. CNAs stated that any medications found on the over-bed table would be reported to a nurse and that residents were not allowed to have unstored medication out in the open in their rooms.
Failure to Complete Significant Change MDS After Hospice Election
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) MDS within 14 days of a resident’s hospice service election, as required by the CMS RAI Manual. The resident had a terminal prognosis related to Parkinson’s disease and a quarterly MDS dated 02/20/2026 showed severe cognitive impairment (BIMS score of 4) and no hospice services. The care plan, reviewed on 03/16/2026 and revised on 04/07/2025, was updated with an intervention initiated on 04/20/2026 indicating that a named hospice provider would supply a CNA up to five times weekly, an RN weekly and PRN, social services monthly and PRN, and chaplain services monthly and PRN, with a contact number listed. A CNA reported that the resident’s baths were being provided by hospice aides who visited about three days a week. Record review showed no physician’s order for hospice services in the electronic health record at the time of survey, and progress notes from 03/01/2026 through 04/24/2026 contained no hospice notes. During interview, the MDS Coordinator stated she completes all MDS assessments and had not done a significant change MDS for this resident’s hospice admission because there was no physician’s order in the system to alert her. Upon review, she identified that an order to admit the resident to hospice services was dated 03/24/2026 but was not entered into the system until 04/23/2026, and acknowledged that the ARD should have been set within 14 days of hospice election, by 04/07/2026. The DON stated that the nurse on duty when the resident was admitted to hospice should have entered an admission order for hospice and expressed that she believed nurses understood they were responsible for adding such orders, treating them like any other order.
Failure to Care Plan Communication Deficit for Nonverbal Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive, person-centered care plan addressing a communication deficit for a nonverbal resident. The resident had been admitted with diagnoses including nontraumatic intracerebral hemorrhage in the brain stem, major depressive disorder, and anxiety disorder, and was unable to move the right side of the body, including the face and mouth, due to a stroke. The admission MDS documented unclear speech, that the resident rarely or never made themself understood, sometimes understood others, and responded adequately only to simple, direct communication, while the BIMS score was 15, indicating intact cognition. The Baseline Care Plan noted the resident did not communicate easily with staff, but on review of the Comprehensive Care Plan initiated at admission, no communication deficit with corresponding interventions had been initiated. Record review showed multiple assessments and notes documenting the resident’s nonverbal status and alternative communication methods, but these findings were not translated into a specific communication care plan problem with individualized interventions. The Nursing Admit/Readmit/Quarterly Assessment described the resident as soft spoken and mouthing words, and progress notes indicated the resident was very soft spoken, nonverbal, able to shake the head yes and no, and utilized sign language. A social services admission assessment documented that the resident’s speech was clear, that the resident was nonverbal, used sign language as another mode of communication, and rarely or never was able to make themself understood but could understand others. An APRN note and an SLP evaluation further confirmed that the resident communicated by nodding or shaking the head and had impaired communication skills. Interviews with staff demonstrated that, in the absence of a care-planned communication deficit with defined interventions, staff relied on general approaches and did not have consistent tools or guidance for communicating with the resident. CNAs and an RNA reported communicating with the resident by asking yes/no questions, observing body language and facial cues, and noting that the resident used the left hand to indicate numbers or point to areas of pain, while also stating they did not know sign language and had not seen communication boards or other aids. An LPN reported talking to nonverbal residents as to verbal residents, using facial expressions to interpret needs, and was unaware of any communication boards or specific interventions for nonverbal residents. The MDS coordinator and DON acknowledged that a communication deficit should have been triggered and care planned at admission for a nonverbal resident, and the DON further stated the facility did not have policies for care plans, comprehensive care plans, communication, or communicating with nonverbal residents.
Failure to Use Required Gait Belt During Transfer Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to utilize appropriate transfer equipment, specifically a gait belt, during a toilet transfer for one resident, resulting in a fall and knee abrasion. The resident had medical diagnoses including a left lower leg blood clot, stage 4 kidney disease, type 2 diabetes, neuropathy, and was care planned as high risk for falls with gait and balance problems and limited mobility related to weakness. The resident was also non‑weight bearing on the left lower extremity and required assistance of two staff members with all transfers. The admission MDS showed the resident was cognitively intact and had a history of a fall in the prior months. Prior to the cited incident, the resident had experienced multiple falls at the facility. An unwitnessed incident report documented that the resident slid out of a wheelchair while trying to pick up a ring from the floor, with no injury. A later witnessed incident documented that the resident’s legs gave out during a transfer, and the resident was assisted to the floor without injury and then transferred back to the wheelchair using a gait belt and two staff. These events established that the resident had recurrent episodes of legs “giving out” and required two‑person assistance and a gait belt for safe transfers. On the date of the deficiency, during a transfer from wheelchair to toilet in the bathroom, two staff members (a MA‑C and a CNA) attempted to stand and pivot the resident using the right leg while the resident held onto grab bars, but they did not use a gait belt. The resident’s legs collapsed, and the resident went down to the knees, sustaining an abrasion to the right kneecap, which the resident attributed to the lack of a gait belt. Interviews with the resident, nursing staff, therapy staff, and administration confirmed that the resident was non‑weight bearing on the left leg, required two‑person assistance and a gait belt for transfers, and that facility expectations and policy required use of a gait belt for all assisted transfers. Staff involved acknowledged they “forgot” to use the gait belt during this transfer, and other staff confirmed that gait belts were expected to be used with every transfer when assistance was needed.
Failure to Maintain Active Oxygen Orders and Humidified Oxygen for Resident Comfort
Penalty
Summary
The deficiency involves the facility’s failure to ensure that oxygen therapy orders were properly scheduled and active before administration and to provide humidified oxygen in accordance with a resident’s preferences and comfort needs. Resident #125, who had diagnoses including respiratory failure, heart failure, and type II diabetes, had an active order entered on 04/15/2026 for oxygen at 2–4 liters via nasal cannula, but the order lacked a start date and did not appear as a scheduled order in the electronic record. The admission MDS in progress with an ARD of 04/20/2026 did not indicate that the resident was receiving oxygen therapy, despite documentation on the resident’s oxygen saturation summary that the resident was on oxygen on multiple dates in April. An LPN confirmed that the oxygen order had been present since 04/15/2026 but was not set up as a scheduled order and had no active date. The facility also failed to provide and maintain humidified water for the resident’s nasal comfort over several days. On multiple observations from 04/20/2026 through 04/22/2026, the resident’s humidifier bottle was found undated or dated but empty, while the resident was receiving 2 liters of oxygen via nasal cannula. The resident repeatedly reported that their nose was very dry and that the humidifier bottle had been empty since Monday, and stated they had asked staff to change the water bottle but could not identify to whom. An LPN acknowledged that the humidified water bottle dated 04/21/2026 was empty and stated it should not have been empty at 2 liters of oxygen, suspecting that someone may have dated an empty bottle without actually changing it. The administrator and DON stated their expectation that humidified water bottles be changed on Tuesday evenings with the tubing or when empty, but there was no facility policy addressing oxygen tubing, storage, or humidified water bottles, and the existing oxygen safety policy only addressed handling oxygen, not equipment.
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