Diversicare Of Amory
Inspection history, citations, penalties and survey trends for this long-term care facility in Amory, Mississippi.
- Location
- 1215 Earl Frye Drive, Amory, Mississippi 38821
- CMS Provider Number
- 255119
- Inspections on file
- 21
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Diversicare Of Amory during CMS and state inspections, most recent first.
Infection control practices were not followed during meal service, medication administration, and biohazard waste storage. Staff passed meal trays to multiple residents without hand hygiene between rooms, including after contact with another resident in the hallway. An RN administered meds to a resident with dysphagia via PEG tube while using the same gloves after resident contact, handled meds with gloved hands, and brought the med cart into the room. Unsecured biohazard waste containing used gowns, gloves, and needles was also observed outside the locked biohazard room, and the room key was left accessible.
An RN fed a resident fortified pudding in a common TV area while other residents were present and remained standing instead of sitting at eye level during the feeding. The RN acknowledged she forgot to sit, and the ADON confirmed staff were expected to sit while feeding residents to promote dignity during meals. The resident had dementia and a BIMS score of 4, indicating severely impaired cognition.
Failure to Maintain a Homelike Environment: A resident’s wall behind the bed had a large area of missing paint with exposed sheetrock, and the condition was described as ongoing. The Maintenance Supervisor said staff and family had been told not to push the bed against the wall, but the issue continued and had not been reported through work orders. The Administrator confirmed the condition did not meet the expectation for a home-like environment. The resident had a hx of moderate protein-calorie malnutrition and a BIMS score of 10, indicating moderately impaired cognition.
A facility failed to carry out care plan interventions for ADLs and wound care for three residents. One resident with a self-care deficit had long, dirty fingernails despite a care plan for daily nail care, another resident with a self-care deficit waited about an hour for toileting assistance after requesting a bedpan, and a third resident with wound care orders had multiple missed Dakins solution and packing treatments documented on the TAR. The DON and MDS RN acknowledged the failures to follow the care plans and ordered treatments.
Failure to Provide Timely ADL Assistance and Nail Care: Two residents had unmet ADL needs. One resident with hemiplegia and hemiparesis following CVA had long, jagged, dirty fingernails despite stating a preference for them to be trimmed, and the DON confirmed nail care was not provided. Another resident with CVA and intact cognition requested a bedpan but was left waiting while meal trays were passed; CNA assistance was delayed for about an hour, and RN, DON, and ADON confirmed the toileting delay was inappropriate.
A resident with diabetic wounds, cellulitis, and osteomyelitis had ordered wound care that was not consistently completed or documented. The TAR showed multiple missed Dakins solution treatments and moist-to-dry packing for the heel and lower leg wounds, and an LPN acknowledged she sometimes provided care without documenting it and could not confirm several treatments due to missing records. The DON confirmed that undocumented care was considered not completed and acknowledged multiple ordered wound treatments were missed.
A resident with a suprapubic catheter for bladder cancer reported he could not remember the last time it had been changed. The resident had a physician order for the catheter to be changed every 30 days on the 26th of the month, but the TAR had no documentation that the catheter was changed as ordered, and the DON confirmed the missing documentation.
Medication was left unattended at the bedside for one resident, and a prescription bottle of Nystatin powder belonging to another resident was found at a different resident’s bedside. An LPN acknowledged leaving oral meds at the bedside despite knowing they should not be left unattended, and the DON confirmed the expectation was to observe the resident swallow the meds. The bedside Nystatin bottle was not from the facility pharmacy and there was no active order for it.
A resident with moderate cognitive impairment and a history of cerebral infarction reported that a CNA was consistently rude, disrespectful, rushed, and too rough during care, despite the resident’s polite requests. Facility grievance documentation and the Administrator’s interview confirmed that the CNA did not provide gentle care and that the resident’s right to dignity and respect, as outlined in facility policy, was not honored. Progressive discipline records showed ongoing concerns from staff, residents, and family about the CNA’s rough handling of patients, delayed assistance, and absence from the assigned hallway, even though the CNA had previously completed abuse/neglect and resident rights training.
The facility did not ensure that new LPNs and CNAs received and completed required skills competency checkoffs before providing care. One new nurse worked independently without a preceptor or skills review, and documentation for two CNAs lacked signatures and verification of completed competencies. The Clinical Educator and Administrator confirmed that skills checkoffs were not completed or documented for these new hires.
A CNA verbally threatened a cognitively intact resident by stating she would slap him and put him in the morgue during an argument after closing a door in his face. Two other residents, also cognitively intact, corroborated hearing the threats and the argument. The CNA admitted to cursing at the resident, and the administrator confirmed this conduct met the facility's definition of verbal abuse.
The facility's QAPI committee failed to maintain and monitor interventions after a recertification survey, leading to repeated deficiencies. Significant staff turnover, including the Infection Control Nurse/Educator, contributed to the halting of EMBRACE rounds, which are designed to identify and correct issues. While issues were identified, follow-up was insufficient, resulting in persistent deficiencies.
The facility failed to implement adequate infection control measures, including monitoring for Legionella, proper storage of respiratory equipment, and adherence to Enhanced Barrier Precautions (EBP) for residents with wounds and indwelling devices. Maintenance staff did not document water safety measures, and respiratory equipment was improperly stored on the floor. Staff also failed to use EBP during wound care and IV administration, increasing infection risk.
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in their care. A resident with Chronic Kidney Disease did not have vital signs documented before and after dialysis sessions, while another with pressure ulcers did not receive proper wound care due to the lack of enhanced barrier precautions. Other residents experienced issues with personal hygiene, Activities of Daily Living (ADLs), TED hose application, and respiratory equipment storage, indicating a broader failure in care plan implementation.
The facility failed to maintain personal hygiene for three residents, resulting in long, dirty fingernails and unkempt appearances. A resident with Hemiplegia had long, dirty nails, while another with Traumatic Subdural Hemorrhage had dirty, jagged nails and unkempt facial hair. A third resident had long ear hair and jagged nails. Staff confirmed the lack of care, acknowledging potential risks of bacterial spread and skin concerns.
The facility failed to provide appropriate treatment and care for two residents. One resident did not receive TED hose as ordered for orthostatic blood pressures, and staff were unaware of the order. Another resident had untreated skin tears with no treatment orders, risking infection and delayed healing. Observations and staff interviews confirmed these deficiencies.
The facility failed to store controlled drugs in a locked, permanently affixed compartment. An unopened box of Lorazepam Concentrate was found on a refrigerator shelf among non-narcotic medications, rather than in the secure lock box. An LPN confirmed the improper storage, and the DON noted the lock box was full, which may have led to the issue. She stated staff should have informed her, as improper storage could lead to missing medications and potential diversion.
The facility failed to provide a safe, clean, and homelike environment for its residents. Observations revealed rusted and damaged overbed tables, a wheelchair with a torn armrest and unclean frame, and a bathroom with unsanitary conditions. The DON confirmed these issues, which affected residents with moderate cognitive impairments and various medical conditions.
The facility failed to allow residents to smoke during inclement weather, despite having a pavilion for shelter. Residents, including those with nicotine dependence, were unable to exercise their right to smoke due to a policy prohibiting smoking during bad weather. Staff confirmed the enforcement of this policy, and the facility's admission paperwork did not inform residents of these restrictions.
A facility failed to include personal hygiene interventions in a baseline care plan for a resident with moderate cognitive impairment and a diagnosis of Traumatic Subdural Hemorrhage. Observations revealed the resident had jagged, dirty fingernails and unkempt facial hair. The DON confirmed the care plan did not address ADL care, despite the resident's need for assistance.
A facility failed to maintain ongoing communication with a dialysis center for a resident with Chronic Kidney Disease Stage 5, leading to incomplete documentation of pre-and post-dialysis vital signs. This deficiency resulted in billing issues for dialysis services, as communication sheets were not consistently completed or sent. The facility's staff, including the DON and Administrator, were unaware of the missing records, with the last communication recorded in the previous year.
The facility failed to maintain accurate reconciliation and accounting for controlled medications in one of the narcotic storage areas. An LPN gave the medication cart keys to the Medical Records nurse, violating policy. Narcotics in the medication room refrigerator were not counted during shift change reconciliation, leading to a deficiency in controlled substance accountability.
A facility failed to include a stop date for a PRN Ativan order for a resident with dementia, leading to a deficiency. The resident received the medication for anxiety and agitation, particularly on shower days, without a stop date for re-evaluation. The absence of a stop date was confirmed by an RN, and the DON explained its necessity for ongoing assessment.
The facility failed to honor the beverage preferences of two residents during dining observations. One resident, moderately cognitively impaired, requested a large glass of tea but was only given a small one due to family concerns about caffeine. Another resident, severely cognitively impaired, requested coffee at lunch but was denied as coffee was only served at breakfast. The Memory Care Coordinator and Administrator confirmed that residents' preferences should be honored, and coffee was available throughout the day.
A resident with Alzheimer's Disease was inappropriately restrained by a CNA in the Memory Care Unit, who prevented her from standing up by placing a knee between her legs. The resident, who was anxious and repeatedly requested to use the bathroom, was told to remain seated despite being on a toileting program. The facility's staff confirmed that the CNA's actions were not in line with the policy on residents' rights.
The facility failed to deliver mail to residents on Saturdays, as confirmed by resident council feedback and staff interviews. Despite a policy ensuring prompt mail delivery, residents reported not receiving mail on Saturdays, with mail left for the social worker to distribute during the week. The administrator was unaware of this issue, although a manager was supposed to handle mail distribution on Saturdays. All affected residents were cognitively intact.
The facility failed to mail written notifications of hospital transfers to the Resident Representatives for two residents. One resident was transferred following a fall, and another due to altered mental status. Social Services did not send the notifications, as the staff member was unaware it was her responsibility. The facility's policy requires such notifications, but they were not provided in these cases.
A facility failed to accurately complete an MDS medication assessment for a resident, incorrectly coding an antiplatelet medication as an anticoagulant. The resident, admitted with Cerebral Ischemia, was prescribed Brilinta, an antiplatelet, but the MDS inaccurately reflected this as an anticoagulant. Interviews with the MDS Coordinator and DON confirmed the error, highlighting a deficiency in the assessment process.
Infection Control Failures During Meal Service, Medication Administration, and Biohazard Waste Storage
Penalty
Summary
The facility failed to implement infection control practices during meal service, medication administration, and biohazard waste storage. The facility’s infection control policy stated that its policies and practices were intended to maintain a safe, sanitary, and comfortable environment and help prevent and manage transmission of diseases and infections. During lunch tray pass observations on 4/13/26 and 4/14/26, staff did not perform hand hygiene between residents while delivering and setting up meal trays on A-Wing. CNA #1 passed trays to multiple residents without sanitizing her hands between rooms, CNA #2 handled trays and entered resident rooms without hand hygiene, and CNA #3 and CNA #4 also delivered trays between rooms without washing or sanitizing their hands. CNA #4 additionally shook hands with an unsampled resident in the hallway and then continued tray delivery without hand hygiene. Staff interviews confirmed they knew hand hygiene was expected between residents but did not perform it. During medication administration on 4/15/26, RN #4 administered medications to Resident #23 through a PEG tube. Resident #23 had been admitted on 3/30/26 with dysphagia. RN #4 pushed the medication cart into the resident’s room, washed her hands, applied gown and gloves, and assisted with repositioning the resident. Using the same gloves, she returned to the medication cart, retrieved a measuring tape, measured the PEG tube, and then prepared medications without changing gloves after resident contact. She handled the resident’s medications by placing tablets in the palm of her gloved hand before placing them into medication packets, then crushed the medications and changed gloves before administering them by PEG tube. RN #4 confirmed she should have changed gloves after resident contact and before medication preparation, and that the medication cart should have remained in the hallway. On 4/16/26, unsecured biohazard waste was observed in two red barrels outside the locked biohazard room. One barrel contained used gowns, gloves, and a sharps container with used needles, and the lid was not locked. The outdoor biohazard room door was locked, but the key was stored above the door frame and was accessible. The Maintenance Supervisor and Administrator both confirmed that biohazardous waste should not be stored outside unsecured and that the key should not be accessible in that manner.
Failure to Preserve Resident Dignity During Feeding
Penalty
Summary
The facility failed to ensure a resident's right to dignity during feeding for one resident observed at mealtime. During an observation, an RN fed Resident #4 fortified pudding in the common television area while other residents were present, and the RN remained standing beside the resident rather than sitting at eye level throughout the feeding. During interview, the RN acknowledged she did not sit while feeding the resident and stated she forgot she was expected to sit while feeding residents. The ADON later confirmed staff were expected to sit while feeding residents to promote dignity during meals. Resident #4 was admitted with dementia, and the MDS documented a BIMS score of 4, indicating severely impaired cognition.
Failure to Maintain a Safe, Clean, and Homelike Resident Environment
Penalty
Summary
The facility failed to ensure Resident #124’s right to a safe, clean, and homelike environment. During observation, the wall behind the resident’s headboard had a large area of missing paint measuring approximately four feet by four feet, and in some areas the top layer of sheetrock was visible. The facility’s Residents’ Rights and Quality of Life Policy stated that residents have the right to receive services in a center environment that is safe, clean, and comfortable. During interview, the Maintenance Supervisor stated the damaged wall behind Resident #124’s bed was an ongoing issue and that staff and family had been educated not to push the bed against the wall, but the condition continued to occur. He reported staff completed daily rounds to identify maintenance concerns, but this issue had not been reported. A review of work orders from 2/18/26 through 4/15/26 showed no work orders to repair the wall. The Administrator confirmed residents were expected to live in a home-like environment and that the large area of missing paint did not meet that expectation. Resident #124 was admitted on 2/14/24 with diagnoses including Moderate Protein-Calorie Malnutrition, and the quarterly MDS showed a BIMS score of 10, indicating moderately impaired cognition.
Failure to Follow Care Plans for ADLs and Wound Treatments
Penalty
Summary
The facility failed to implement comprehensive care plan interventions for Activities of Daily Living for two residents and wound care for one resident. The facility policy stated that care plans would be developed and implemented for all residents based on RAI guidelines. The deficiencies were identified through resident and staff interviews, record review, and observation, and involved failure to follow documented care plan interventions and ordered treatments. Resident #108 had a care plan for self-care deficit that included nail, hair, and oral care daily and as needed. During observations, the resident had long fingernails, approximately 3/4 inch from the nailbed, with a brown substance under the nails, and stated he preferred his fingernails to be kept short and trimmed. The DON later observed the nails and confirmed they were long, jagged, and dirty. Resident #108 had diagnoses including hemiplegia and hemiparesis following cerebral infarction, and the MDS showed a BIMS score of 13, indicating cognitive intactness. Resident #102 had a care plan for self-care deficit with toileting hygiene requiring substantial to maximum assistance. She reported requesting a bedpan at about 8:00 AM and stated staff had not returned to assist her, leaving her uncomfortable with a full bladder. CNA #1 stated she was going to assist the resident about one hour and four minutes after the request, and the DON stated the CNA should have assisted at the time of the request. Resident #102 had diagnoses including cerebral infarction and a BIMS score of 14, indicating cognitive intactness. Resident #3 had care plan interventions for wound care with treatments as ordered, but the TAR showed multiple missed treatments for the right heel wound and right lateral lower leg wound, including missed Dakins solution treatments and missed moist-to-dry packing. The MDS RN and DON acknowledged that wound care was part of the care plan and that the facility failed to follow the developed care plan for treatments as ordered.
Failure to Provide Timely ADL Assistance and Nail Care
Penalty
Summary
The facility failed to provide ADL services in accordance with its policy, resulting in unmet care needs for two residents reviewed for ADL care. The facility policy titled ADL's, dated August 2021, stated that ADLs are to be provided in accordance with accepted standards of practice, the care plan, and the resident's choices and preferences. Resident #108, who had diagnoses including hemiplegia and hemiparesis following cerebral infarction and a BIMS score of 13, stated he preferred his fingernails kept short and wanted them trimmed. During observation, his fingernails were noted to be long, jagged, and dirty with a brown substance under each nail. The DON observed the nails and confirmed they were long, jagged, and dirty, and acknowledged the facility failed to provide nail care for a dependent resident. Resident #102, who had diagnoses including cerebral infarction and a BIMS score of 14, was observed lying in bed and reported she was unable to get up without assistance and had requested a bedpan but had not received help. She stated staff told her assistance would be provided after meal trays were passed, and her breakfast tray had already been delivered and removed without toileting assistance being provided. She activated her call light, and CNA #1 entered the room and exited without providing toileting assistance. CNA #1 later stated she would return with a bedpan, and assistance was not provided until about one hour and four minutes after the initial request. RN #3, the DON, and the ADON all confirmed that the resident should have been assisted when she requested help and that the delay was not appropriate.
Missed and Undocumented Wound Treatments
Penalty
Summary
The facility failed to ensure necessary wound care was provided and accurately documented for one resident with diabetic wounds to the right lower extremity. The resident was admitted with diagnoses including cellulitis of the right lower limb, acute osteomyelitis of the right ankle and foot, and type 2 diabetes mellitus. During interview, the resident stated that dressings were scheduled to be changed daily and reported that treatments had not been completed on several occasions. At the time of observation, the resident had a dressing and boot in place to the lower right leg. The resident had physician orders for Dakins solution treatment to the right heel wound daily, packing the right heel moist-to-dry with one-quarter strength Dakins solution daily and as needed, and cleaning the right lateral lower leg with one-quarter strength Dakins solution every day shift for cellulitis wound. The treatment record showed no documentation that the right heel Dakins treatment or the right heel moist-to-dry packing was completed on multiple dates in March 2026, and no documentation that the right lateral lower leg treatment was completed on multiple dates in March 2026. The record also showed no documentation that a prior right posterior lower leg treatment was completed on one date in March 2026, and no documentation that the right heel moist-to-dry treatment was completed on one date in April 2026. During interview, an LPN who sometimes provided the resident’s wound care acknowledged she did not document care on occasions when she completed treatments and could not confirm whether some treatments were done because documentation was missing. She also stated she was not assigned to the resident on some of the dates in question and did not complete treatment on at least one date. The DON confirmed that if care was not documented it was considered not completed and acknowledged there were multiple dates where ordered wound treatments were not completed. The resident’s MDS indicated a BIMS score of 15, showing the resident was cognitively intact.
Failure to Change Suprapubic Catheter as Ordered
Penalty
Summary
The facility failed to provide services to prevent possible complications for one resident with an indwelling suprapubic catheter. The resident had diagnoses including malignant neoplasm of the bladder and weakness, and was admitted with a suprapubic catheter in place due to bladder cancer. During observation and interview, the resident stated he had the catheter for a long time and could not remember the last time it had been changed. The resident had a physician order dated 1/26/26 for the suprapubic catheter to be changed every 30 days on the 26th of each month. RN #3 stated catheters were to be changed monthly unless otherwise specified and that the treatment nurse was responsible for completing catheter change orders on the TAR. The DON reviewed the TAR and confirmed there was no documentation that the suprapubic catheter was changed in March 2026, despite the order for a monthly change on the 26th.
Medication Left at Bedside and Improperly Stored
Penalty
Summary
The facility failed to ensure medications were securely stored and administered in a manner that prevented them from being left unattended at the bedside for two residents. Facility policy stated that medications should not be left at the bedside and should be accessible only to authorized personnel. During observation and interview, Resident #35 was seen placing four medication tablets from a medication cup into her hand and swallowing them after reporting that the nurse had left the medications, along with others she had already taken, at her bedside several minutes earlier. The LPN acknowledged leaving the medications at the bedside and stated she knew it was not safe to do so, while the DON confirmed the expectation was to remain with the resident and observe medication ingestion. The facility also failed to ensure proper storage of a medication found at Resident #44's bedside. During observation, a prescription bottle of Nystatin powder with a label was found on the bedside table. The Interim DON later confirmed the bottle belonged to the resident's roommate, Resident #92, and was not from the facility pharmacy. The medication was removed from the room, and the Interim DON stated prescription medications should not be left at the bedside, especially medications from an unknown source. Resident #44 had a BIMS score of 15 and no active physician's order for Nystatin powder.
Failure to Ensure Resident Dignity and Respect During CNA Care
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s right to be treated with dignity and respect. The facility’s policy, “Your Resident Rights and Protections Under State and Federal Law” (dated 2022), states that residents have the right to be treated with consideration and respect in full recognition of their dignity and individuality. Resident #1, who was admitted with a diagnosis including cerebral infarction and had a BIMS score of 11 indicating moderate cognitive impairment, reported that a CNA was rude, disrespectful, always rushing, and did not provide care in a gentle manner. A Customer Concern Log and a Customer Concern/Grievance Communication Form dated 12/17/25 documented the resident’s report that the CNA was “too rough,” had a bad attitude, and did not stop the behavior despite the resident using good manners and expressing concerns. Interviews with the Administrator on 2/5/26 confirmed that CNA #1 did not provide gentle care and was rude and disrespectful to Resident #1, and that the resident’s right to dignity and respect was not honored. Progressive Discipline Forms for CNA #1 dated 12/16/25 and 12/18/25 documented continued poor work quality and productivity, including concerns from staff, residents, and family members about the CNA being too rough when handling patients, not getting patients out of bed timely, and not being present on the hallway at assigned times. Despite CNA #1 having completed Abuse, Neglect, and Exploitation training and Compliance Training on 8/31/25, as well as training on Patient/Resident Rights on 6/25/24, the facility failed to ensure that Resident #1 was consistently treated with dignity and respect during care interactions.
Failure to Complete Skills Competency Checkoffs for New Nursing Staff
Penalty
Summary
The facility failed to ensure that newly hired licensed nurses and certified nurse assistants (CNAs) received skills competency checkoffs before providing resident care. Three new hires were reviewed, and none had completed or documented skills checkoffs as required by facility policy. One graduate practical nurse reported not being assigned a preceptor, not receiving a skills checkoff form, and not having her skills reviewed before working independently. She also stated she felt overwhelmed with charting and other processes that were not reviewed with her during orientation. The Clinical Educator confirmed that she had not performed any skills checkoffs with the new nurse and was unaware if the previous Director of Nursing had done so. Additionally, the Clinical Educator acknowledged that she had never obtained completed new hire skills checkoffs since starting her role and was often pulled away from her educator duties to work on the medication cart. Review of documentation for two CNAs revealed that required skills checklists and audit tools were either unsigned, undated, or missing staff and trainer names, making it impossible to verify that competencies had been completed. The Administrator confirmed that the facility could not locate any skills review forms for the new nurse and acknowledged that all new hires should have skills checkoffs to ensure competency. The lack of completed and documented skills checkoffs for new hires resulted in the facility's failure to ensure staff competency prior to providing resident care.
Verbal Abuse by CNA Toward Resident
Penalty
Summary
A deficiency occurred when a certified nurse assistant (CNA) verbally threatened a resident, failing to protect the resident from verbal abuse as required by facility policy and federal and state regulations. The incident involved a cognitively intact resident who reported that the CNA shut a door in his face, refused to let him into the smoking area, and subsequently engaged in an argument with him. During the altercation, the CNA told the resident she would slap him and, when the resident threatened to call the police, stated she would put him in the morgue. The resident confirmed these statements during an interview, and another cognitively intact resident corroborated hearing the threats and the argument. A third resident also reported hearing the argument and the accusation regarding the door being closed. The facility's investigation included interviews with the involved residents and the CNA. The CNA denied making the specific threats but admitted to cursing at the resident after being cursed at. The administrator confirmed that the CNA's actions, including cursing and the threats, constituted verbal abuse according to facility policy, which defines verbal and mental abuse as conduct that can cause fear, humiliation, or intimidation. The residents involved were all cognitively intact, as indicated by their Brief Interview for Mental Status (BIMS) scores. The incident was substantiated based on resident interviews and the facility's internal investigation.
QAPI Program Ineffectiveness and Staff Turnover Lead to Repeated Deficiencies
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain and monitor the interventions implemented after the recertification survey conducted on October 19, 2023. This failure was evident during a subsequent recertification and complaint survey on February 13, 2025, where several deficiencies were re-cited, including F 584, F 656, F 677, F 684, F 761, and F 880. The facility's inability to sustain an effective QAPI program was highlighted by the recurrence of these deficiencies, indicating a pattern of non-compliance. The facility's policy on QAPI, dated February 2017, emphasizes a proactive approach to improving quality of life, care, and services, involving team members at all levels to identify and address gaps in systems or processes. Interviews with the Administrator and Director of Nursing revealed significant staff turnover, including the Infection Control Nurse/Educator, which contributed to the halting of the facility's EMBRACE rounds from November 2024 until January 2025. The EMBRACE rounds, designed to identify and correct issues, were not effectively followed up on, leading to persistent deficiencies. The Administrator acknowledged that while issues were identified during these rounds, the follow-up was insufficient to ensure correction. The Director of Nursing confirmed that identified issues were initially audited and monitored but eventually neglected, resulting in a lack of sustained corrective action.
Infection Control Deficiencies in Water Management and Equipment Storage
Penalty
Summary
The facility failed to implement adequate infection prevention and control measures, as evidenced by several deficiencies. Firstly, the facility did not have procedures in place to monitor and test the water source for Legionella's Disease, which could potentially affect all residents. During an interview, the maintenance staff revealed that while they changed shower heads and flushed unused water sources, they did not keep logs or monitor the effectiveness of these measures. The administrator confirmed the lack of documented monitoring and testing of the water system, acknowledging the potential health risks posed by Legionella and other waterborne illnesses. Additionally, the facility failed to properly store respiratory equipment for a resident with lung issues. Observations revealed that the resident's nebulizer, tubing, and mask were stored on the floor, which the Director of Nursing confirmed was unacceptable and posed a risk of respiratory infection. Despite the resident's concerns, the equipment remained improperly stored, indicating a lapse in infection control practices. The facility also did not adhere to Enhanced Barrier Precautions (EBP) for residents with wounds and indwelling medical devices. During wound care for a resident with a chronic wound, staff failed to don gowns as required by EBP. Another resident with a PICC line did not have EBP signage, and staff did not use gowns during IV antibiotic administration. Interviews with staff revealed a lack of awareness and understanding of EBP requirements, which the Director of Nursing confirmed increased the risk of infection spread among vulnerable residents.
Deficiencies in Care Plan Implementation
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in their care. Resident #8, who has Chronic Kidney Disease and requires dialysis, did not have vital signs documented before and after dialysis sessions in January 2025, as required by their care plan. The Director of Nurses confirmed the absence of these records, which were supposed to be communicated between the facility and the dialysis center. This lack of documentation indicates that the care plan for Resident #8 was not followed. Resident #11, who has multiple pressure ulcers, did not receive proper wound care as enhanced barrier precautions (EBP) were not followed during treatment. The Director of Nursing and MDS Coordinator confirmed that EBP was part of the wound care guidelines, but it was not listed as a separate intervention in the care plan. This oversight led to the care plan not being fully implemented, as EBP was not used during wound care. Other residents, including Resident #62, #74, #253, and #82, also experienced deficiencies in their care plans. Resident #62 lacked a care plan for personal hygiene, resulting in untrimmed and dirty nails. Resident #74 did not have a care plan for Activities of Daily Living (ADLs), leading to unkempt personal appearance. Resident #253's care plan for TED hose application was not implemented, as the resident was observed without the hose. Lastly, Resident #82 did not have a care plan for the proper storage of respiratory equipment, which was found improperly stored on the floor. These deficiencies highlight the facility's failure to develop and implement comprehensive care plans for its residents, impacting their overall care and well-being.
Deficiency in Personal Hygiene Care for Residents
Penalty
Summary
The facility failed to provide adequate personal hygiene care for three residents, leading to deficiencies in maintaining their personal hygiene. Resident #62 was observed with long, dirty fingernails containing a dark brown substance, and expressed a desire to have them trimmed. The CNA confirmed the lack of nail care, and the DON acknowledged the potential for bacterial spread and skin concerns due to inadequate hygiene. Resident #62 was admitted with a diagnosis of Hemiplegia and Hemiparesis following a Cerebral Infarction and was cognitively intact, requiring setup or clean-up assistance for personal hygiene. Resident #253 was observed with dirty, jagged fingernails and unkempt facial hair. The COTA confirmed the resident's nails were dirty the previous week, and the DON acknowledged the need for nail care. Resident #253 was admitted with a diagnosis of Traumatic Subdural Hemorrhage and was moderately cognitively impaired, requiring partial/moderate assistance for personal hygiene. Resident #74 was observed with long ear hair and jagged fingernails with a brown substance underneath. The Memory Care Unit Coordinator confirmed the resident's condition and noted the aides' responsibility for nail care during showers. Resident #74 was admitted with a diagnosis of Cerebral Infarction.
Failure to Provide Appropriate Treatment and Care
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards of practice for two residents. For Resident #253, there was a physician's order for the application of TED hose every morning and removal every night due to orthostatic blood pressures. However, observations on multiple occasions revealed that the resident was not wearing TED hose, and staff, including a CNA and an LPN, were unaware of the order or the presence of the TED hose. The lack of adherence to the physician's order could lead to increased episodes of orthostatic hypotension for the resident. For Resident #303, the facility failed to address skin concerns appropriately. Observations revealed that the resident had foam dressings on the left elbow with drainage, but there were no orders for skin treatment. A review of the resident's progress notes indicated a fall resulting in a skin tear, but there was no follow-up treatment order. An RN confirmed the lack of awareness and treatment for the skin tears, which could lead to infection or delayed healing. The facility's failure to monitor and treat the resident's skin tears according to professional standards of practice was evident.
Improper Storage of Controlled Drugs
Penalty
Summary
The facility failed to store controlled drugs in a locked, permanently affixed compartment as required by their policy. During an observation of the medication room refrigerator, an unopened box of Lorazepam Concentrate was found sitting on a shelf among other non-narcotic medications, rather than in the secure lock box designated for controlled substances. This was confirmed by an LPN who acknowledged the improper storage. The Director of Nursing also confirmed the deficiency, noting that the secure lock box was full, which may have led to the Lorazepam being placed on the refrigerator shelf. She stated that staff should have informed her of the issue, as improper storage of narcotics could lead to missing medications and potential diversion.
Facility Fails to Maintain Safe and Clean Environment for Residents
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by several deficiencies observed during a survey. In Resident #48's room, two overbed tables were found with thick rust on their metal bases and torn, jagged edges, which the Director of Nursing (DON) confirmed needed replacement. Resident #48 had been admitted with diagnoses including Unspecified Dementia and Peripheral Vascular Disease. Resident #60 was observed in a wheelchair with a torn armrest and a dark-gray substance on the frame and spokes of the wheels. The resident reported using the wheelchair for three weeks in this condition. The DON confirmed the wheelchair's condition could cause a skin tear and needed cleaning. Resident #60 had a moderate cognitive impairment, as indicated by a BIMS score of 9. In room C-7, a bathroom inspection revealed a raised toilet seat with a large dried dark brown substance, identified as stool, on the seat rim and metal bar. The DON acknowledged this as an infection control concern. Additionally, Resident #99's room had a large section of missing paint behind the headboard and a rusted overbed table, which the DON confirmed did not meet the standard for a clean, comfortable, and homelike environment. Resident #99 had been admitted with diagnoses including Traumatic Subdural Hemorrhage and Dysphagia, and also had a moderate cognitive impairment with a BIMS score of 9.
Residents' Right to Smoke Restricted During Inclement Weather
Penalty
Summary
The facility failed to ensure that residents had the right to participate in smoking during rainy or inclement weather, as observed over two of the four survey days. The facility's policy prohibited staff from taking residents out to smoke during inclement weather, including rain, sleet, snow, storms, extreme heat, and freezing temperatures. This policy was enforced despite the presence of a pavilion that could provide shelter. Multiple residents, including those with nicotine dependence and cognitive impairments, expressed their desire to smoke and their dissatisfaction with the inability to do so due to the weather conditions. Staff interviews confirmed that residents were not allowed to smoke during inclement weather, and the facility's admission paperwork did not address smoking rules, leaving residents uninformed about these restrictions. Resident #60, who has a diagnosis of Major Depressive Disorder and Nicotine Dependence, expressed frustration at not being able to smoke due to the rain. Similarly, Resident #65, with a diagnosis of Heart Failure and Nicotine Dependence, and other residents voiced their concerns about missing their smoking breaks. The facility's policy and its enforcement during inclement weather led to the residents' inability to exercise their right to smoke, which they felt was important for their well-being. The facility's failure to inform residents about smoking restrictions during admission further contributed to the deficiency.
Failure to Address Personal Hygiene in Baseline Care Plan
Penalty
Summary
The facility failed to develop a thorough baseline care plan addressing personal hygiene for a resident admitted with a diagnosis of Traumatic Subdural Hemorrhage. Upon observation, the resident was found to have jagged fingernails with a dark brown substance underneath and unkempt facial hair. These observations were confirmed by a Certified Nurse Assistant and a Certified Occupational Therapist, who noted similar conditions in the past week. A review of the resident's baseline care plan, dated shortly after admission, revealed no interventions related to personal hygiene. The Director of Nursing confirmed that the care plan did not adequately address Activities of Daily Living (ADL) care, specifically personal hygiene. The resident's Admission Minimum Data Set indicated a moderate cognitive impairment, requiring partial to moderate assistance with personal hygiene, which was not reflected in the care plan.
Failure to Document and Communicate Dialysis Care
Penalty
Summary
The facility failed to provide ongoing communication documentation with the hemodialysis center for a resident receiving dialysis services. The resident, who has Chronic Kidney Disease Stage 5 and is dependent on renal dialysis, was admitted to the facility with a physician order for dialysis three times a week. However, the facility did not consistently document or transmit the necessary communication records, including pre-and post-dialysis vital signs, to the dialysis center. Interviews with the resident and staff revealed that vital signs were not always checked before and after dialysis, and communication sheets were not completed or sent to the dialysis center. The lack of communication documentation led to issues with billing for dialysis services, as noted by the MDS nurse, who stated that the facility could not bill for the dialysis services due to incomplete communication sheets. The Director of Nurses and the Administrator were unaware of the missing communication records, which were essential for coordinating care between the facility and the dialysis center. The last recorded communication with the dialysis center was in December of the previous year, indicating a lapse in the required ongoing communication for the resident's care.
Failure in Controlled Substance Accountability
Penalty
Summary
The facility failed to maintain a system of medication records that enables accurate reconciliation and accounting for all controlled medications in one of the three narcotic storage areas reviewed. During an observation of medication administration, an LPN was seen giving the medication cart keys to the Medical Records nurse to retrieve medication from the medication room. This action was against the facility's policy, which states that the medication nurse on duty should maintain possession of the keys to controlled substances. Furthermore, the LPN admitted to not checking the medication room refrigerator for narcotics during the shift change reconciliation, which was confirmed by another LPN who also failed to count the narcotics in the refrigerator. The Director of Nurses confirmed that all narcotics should be reconciled at the beginning and end of each shift to ensure an accurate account. The failure to do so could lead to missing narcotics and possible diversion. Additionally, the Medical Records nurse acknowledged that she should not have accepted the keys from the LPN, as it included access to the refrigerator narcotic box. This series of actions and inactions led to a deficiency in the facility's controlled substance accountability, as the narcotics in the refrigerator were not counted, and the keys were improperly handled.
PRN Psychotropic Medication Lacks Stop Date
Penalty
Summary
The facility failed to ensure a PRN psychotropic medication had a stop date for one of the resident's medications reviewed. Specifically, Resident #69 had an order for Ativan, an antianxiety medication, to be administered as needed for anxiety and agitation, without a stop date. This order was dated December 17, 2024, and was still active in February 2025. The resident, who was admitted to the facility in September 2021 with a diagnosis of unspecified dementia, typically received the medication on shower days due to combative behavior. An interview with a registered nurse confirmed the absence of a stop date, and the Director of Nursing explained that a stop date is necessary for the doctor to re-evaluate the need for the medication.
Failure to Honor Residents' Beverage Preferences
Penalty
Summary
The facility failed to honor the beverage preferences of two residents during dining observations. Resident #13, who was moderately cognitively impaired with a BIMS score of 10, requested a large glass of tea while dining in her room. However, RN #4 provided only a small glass of tea, citing the family's concerns about caffeine intake. The resident expressed a desire to eat in the dining room and have a large glass of tea, but her preference was not accommodated. On the following day, during lunch in the dining area, Resident #13 was again provided with only a small glass of tea. Resident #303, who was severely cognitively impaired with a BIMS score of 3 and had a medical diagnosis of acute kidney failure, requested coffee during lunch. RN #4 informed the resident that coffee was only available during breakfast, and the request was not fulfilled. The Memory Care Coordinator confirmed that residents' preferences should be honored, and the Administrator stated that coffee was available throughout the day, indicating that the staff should have provided it upon request. These actions and inactions led to the deficiency in honoring residents' beverage preferences.
Resident Restrained Without Physician's Order
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, as evidenced by an incident involving a Certified Nurse Aide (CNA) and a resident in the Memory Care Unit. The CNA was observed standing in front of the resident, who was seated in a wheelchair, with her knee between the resident's legs, preventing the resident from standing up. The resident, who was anxious and repeatedly requested to go to the bathroom, was told by the CNA to remain seated. The Memory Care Unit Coordinator confirmed that the CNA was restricting the resident's movement to prevent a fall, as the resident had recently been toileted and was on a toileting program. The resident, who had been admitted with Alzheimer's Disease, was severely cognitively impaired and had recently experienced a decline in behavior and restlessness. The resident's frequent requests to use the bathroom coincided with a urinary tract infection for which she was receiving treatment. Interviews with the facility's Administrator, Director of Nursing, and other staff confirmed that the CNA's actions were inappropriate and constituted a restraint without a physician's order. The CNA had received training on preventing falls and dementia care, but her actions were not aligned with the facility's policy on residents' rights.
Failure to Deliver Resident Mail on Saturdays
Penalty
Summary
The facility failed to deliver resident mail on Saturdays, affecting four residents who attended a Resident Council meeting. According to the facility's policy, residents have the right to receive their mail promptly and unopened. However, during the meeting, residents expressed that they had not been receiving their mail on Saturdays, with one resident noting that the mail remained in the mailbox until the social worker returned during the week. This issue was confirmed by the social worker, who acknowledged the importance of residents receiving their mail and admitted that the mail was left for her to distribute. The facility's administrator was unaware of the issue and stated that a manager on duty on Saturdays was responsible for distributing the mail. The administrator confirmed that mail should be distributed on days it is delivered. The residents involved were all cognitively intact, as indicated by their Brief Interview for Mental Status (BIMS) scores of 15, which suggests they were aware of the deficiency in mail delivery. The failure to deliver mail on Saturdays was a deviation from the facility's policy and residents' rights.
Failure to Notify Resident Representatives of Hospital Transfers
Penalty
Summary
The facility failed to provide written notification of hospital transfer to the Resident Representatives (RR) for two residents who were hospitalized. The facility's policy on transfer and discharge requires that both the resident and their RR be notified in a language and manner they understand before a transfer or discharge occurs. However, in the cases of Resident #63 and Resident #102, this procedure was not followed. Resident #63 was transferred to the hospital following a fall, and Resident #102 was transferred due to altered mental status. Despite these transfers, the required written notifications were not mailed to their RRs. Interviews with facility staff revealed a lack of awareness and communication regarding the responsibility for sending out these notifications. Social Services (SS) #1 confirmed that she did not mail the notifications and was unaware that it was her responsibility, as she had not been instructed by the previous social worker. The facility administrator confirmed that it was indeed the responsibility of Social Services to mail out hospital transfer notices and acknowledged that the notifications should have been sent to the RRs for both residents. Resident #63 had a medical diagnosis of Alzheimer's Disease, and Resident #102 had a diagnosis of Cerebral Infarction due to Unspecified Occlusion or Stenosis of the Left Cerebellar Artery.
Inaccurate MDS Medication Assessment
Penalty
Summary
The facility failed to accurately complete an assessment for the Minimum Data Set (MDS) medication section for one of the sampled residents. Specifically, an antiplatelet medication was incorrectly entered as an anticoagulant medication for a resident. The resident, who was admitted with a diagnosis of Cerebral Ischemia, had an order for Brilinta, an antiplatelet medication, which was inaccurately coded in the MDS as an anticoagulant. This error was identified during a review of the resident's quarterly MDS Section N - Medications. Interviews with the MDS Coordinator and the Director of Nursing confirmed the inaccuracy in the MDS assessment. The MDS Coordinator acknowledged the mistake and emphasized the importance of accurate MDS assessments to reflect the resident's health and abilities. The Director of Nursing also confirmed the error, stating that the MDS should accurately assess the resident's health status at a specific time. The incorrect entry of the medication type in the MDS was a clear deficiency in the facility's assessment process.
Latest citations in Mississippi
A resident with advanced dementia and severe cognitive impairment sustained a bruised left eye and facial bruising after being struck by a CNA. The CNA initially claimed the injury occurred accidentally while pushing the resident to a dining table and denied hitting the resident, but an LPN and another CNA reported that the resident stated she had hit the CNA and was hit back in the eye, demonstrating a slapping motion. Nursing documentation described left orbital ecchymosis, bruising along the bridge of the nose and cheek, tenderness, minimal edema, and the resident’s complaint of soreness, confirming a significant injury resulting from the physical abuse.
The facility failed to protect residents’ right to a dignified and comfortable environment when it did not effectively manage one cognitively impaired resident’s ongoing nighttime yelling, which repeatedly disrupted the sleep of two cognitively intact residents. Staff, including a CNA, the DON, and the Administrator, were aware that this resident, diagnosed with dementia and psychosis, frequently yelled and screamed at night while often sleeping during the day. Progress notes documented nighttime hollering, and interviews confirmed that the disruptive behavior persisted over time, interfering with other residents’ ability to rest.
Surveyors found that the facility failed to protect two residents’ rights to dignity and privacy during routine care. One resident, with moderate cognitive impairment and dependent for toilet hygiene, was observed receiving incontinence care while uncovered, with the room door open and the privacy curtain only partially drawn, allowing visibility into the hallway despite facility policy requiring full privacy. Another resident, dependent for eating and with hemiplegia after a stroke, was assisted with lunch by a CNA who stood over the resident instead of sitting at eye level as required by the facility’s feeding skills checklist. Staff interviews, including with CNAs, an LPN, the DON, and the Administrator, confirmed that existing policies and in-service training directed staff to provide privacy during incontinence care and to sit beside residents when assisting with meals to ensure dignified care.
A resident with epilepsy, skin infection, an upper arm wound, gastrostomy status, and moderate cognitive impairment was observed twice resting in bed with a lunch tray while the call light was not within reach—once on the floor under the bed and once hanging behind the mattress, out of sight. The resident reported being able to use the call light but not knowing where it was. Staff, including CNAs, an LPN, the DON, and the Administrator, stated that call lights are expected to be left within residents’ reach and that training and competencies address this requirement, but there was no specific written policy on call light placement.
A resident with moderate cognitive impairment, dependent for toilet hygiene and with multiple medical conditions, was observed receiving incontinent care in which a CNA removed a urine-soaked brief, changed the bed sheet, and applied a clean brief without performing any required perineal cleansing of the front or back. Facility policy and the peri-care skills checklist specified that male residents must have the perineal area, including the penis, scrotum, and inner thighs, washed, rinsed, and dried during incontinent care. The CNA later acknowledged having been trained and competency-checked on this procedure and knowing cleansing was required. Other staff, including a CNA supervisor, an LPN, the DON, and the Administrator, confirmed that proper incontinent care includes full perineal cleansing in addition to brief changes, establishing that the observed omission did not follow facility policy or professional standards intended to prevent UTIs.
Surveyors found that staff failed to follow infection control practices during PEG tube and wound care. Two residents with PEG tubes had sites with visible brown, crusted or yellowish drainage that had not been cleaned for several days, despite physician orders for daily cleansing and, when indicated, dressings. In another case, a CNA provided peri-care for stool and then assisted with a stage IV sacral pressure ulcer dressing change without changing gloves or performing hand hygiene, contrary to facility policy and staff expectations for aseptic technique.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment when a resident’s room contained odorous soiled linens left on the floor and later placed on furniture with clean clothing, and the bed was made with torn linens exposing the mattress. Other residents reported that housekeeping did not clean under beds, and multiple large dead roaches were repeatedly observed under several beds, with one resident stating he often disposed of dead roaches himself. Residents also reported refusing to use the north shower room due to dirty clothing, feces, and residue on shower chairs and floors; an observation confirmed the presence of soiled clothing, a soiled brief, and unidentified substances on the shower chair and floor, despite staff acknowledging that CNAs were expected to clean and sanitize the shower room after each use.
The facility failed to maintain an effective pest control program, as evidenced by repeated observations of roaches and other insects in multiple resident rooms and common areas. Surveyors found gnats and dead roaches under beds, while several residents reported seeing roaches on ceilings, walls, and floors, including roaches falling onto them at night and having to remove dead roaches themselves. A family member reported bringing her own roach spray due to concerns about roaches in a loved one’s room. During a Resident Council meeting, roaches were seen crawling across the floor, and residents stated that roaches were commonly observed throughout the building. Although the contracted pest control provider reported monthly service focused mainly on entry points and exterior areas and facility staff described processes for reporting pests, the persistent roach activity showed the program was not effectively preventing or controlling pests.
A resident with multiple chronic conditions, who relied on phone contact with a seriously ill significant other, lost access to private communication after her personal cell phone was broken and sent out for repair. Facility policy guarantees residents access to a telephone and private communication, but there was no cordless phone available on the relevant hall, and staff, including the DON, SSD, and Administrator, confirmed there was no convenient method for residents on that hall to make private calls without arranging to use a staff office. This resulted in the resident having no readily available, private telephone option.
A resident with heart failure, chronic kidney disease, hypertension, moderate cognitive impairment, and total dependence on staff for personal and toilet hygiene reported difficulty obtaining assistance with ADLs. Observation revealed the resident had ten long, dirty fingernails extending several millimeters beyond the fingertips with black material underneath, and the resident stated they needed cleaning and cutting. An LPN confirmed the nails were too long and dirty, acknowledged that nursing staff were responsible for daily and weekly fingernail checks and for providing fingernail care as part of ADLs, and noted that such nails could cause skin damage or scratches. The DON and Administrator both confirmed that personal hygiene and grooming are part of ADLs and are expected to be provided for all residents dependent on staff.
Failure to Protect Cognitively Impaired Resident From Physical Abuse by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse, resulting in the resident being struck in the eye by a CNA. Facility records show that a CNA reported to an LPN that the resident had a bruised left eye and initially stated the injury may have occurred while pushing the resident to the dining table due to the resident’s short, stooped posture. The CNA also reported that the resident used a racial slur toward her and that she verbally responded but denied striking the resident. However, subsequent interviews and the facility’s investigation determined that the resident’s injury was not caused by accidental contact with the dining table. Interviews with staff revealed conflicting accounts that led to the conclusion that the resident had been hit. An LPN stated that the resident reported being hit in the eye by the CNA and that another CNA heard a commotion and later observed bruising to the resident’s left eye. When this second CNA asked what happened, the resident reported that she hit the CNA and was hit back in the eye, while making a motion consistent with a slap. The LPN confirmed that the resident gave a similar account to her, indicating that the CNA had physically struck the resident. The resident involved was admitted to the Memory Care Unit with diagnoses including Alzheimer’s disease, cognitive communication deficit, and unspecified dementia with behavioral disturbance, and had a BIMS score of 5 indicating severe cognitive impairment. A nursing progress note documented an acute follow-up assessment of left orbital ecchymosis, describing a dark red circular bruise to the left eye region, dark purple bruising along the lateral bridge of the nose extending to the superior left cheek, tenderness on palpation, minimal edema, and the resident’s complaint that the area was sore. Due to advanced Alzheimer’s disease, the resident was unable to reliably express additional symptoms, but the documented physical findings supported that the resident sustained a significant injury to the eye area as a result of being struck by the CNA.
Failure to Protect Residents’ Right to Rest Due to Unmanaged Nighttime Yelling
Penalty
Summary
The deficiency involves the facility’s failure to ensure a dignified and comfortable environment by not effectively addressing ongoing disruptive nighttime behaviors of one resident that interfered with other residents’ ability to rest. Resident #1, admitted with diagnoses including Psychosis and Dementia and a BIMS score of 4 indicating severely impaired cognition, had documented episodes of hollering and yelling during nighttime hours, as noted in progress notes on 3/12/26 and 3/13/26. Interviews with cognitively intact residents, Resident #2 and Resident #3 (both with BIMS scores of 15), revealed that they frequently experienced disrupted sleep due to Resident #1 yelling loudly at night, while the environment was generally quiet during the day. Staff interviews confirmed awareness of the pattern of behavior. CNA #1, who worked both day and night shifts, reported that Resident #1 frequently yelled and screamed at intervals throughout the night and was generally quiet and often slept during the day, with staff assisting the resident out of bed into a geri-chair during both day and nighttime hours. The DON acknowledged the facility was aware of Resident #1’s increased nighttime yelling and extended daytime rest, attributing it to the resident’s Dementia and Psychosis, and stated that interventions such as monitoring, repositioning, offering care, and attempts at redirection had not stopped the behaviors. The Administrator also confirmed awareness of concerns that nighttime noise from Resident #1 affected other residents’ ability to rest. Despite this awareness and ongoing complaints from other residents, the disruptive nighttime yelling continued, resulting in a failure to uphold residents’ rights to a dignified existence and a comfortable environment.
Failure to Ensure Privacy and Dignified Care During Incontinence Care and Feeding
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were treated with dignity and provided privacy during care, as required by resident rights policies and skills checklists. The facility’s Nursing Facility Resident Rights policy guaranteed residents the right to be treated with dignity, courtesy, and respect, and to have privacy during personal care. Facility skills checklists for feeding and peri/incontinent care specified that staff should sit facing residents at eye level when feeding and provide privacy by drawing curtains and closing doors during incontinence care. For Resident #2, surveyors observed a CNA providing incontinent care without closing the resident’s room door and with the privacy curtain only partially drawn. From the surveyor’s position at the bottom right corner of the bed, it was possible to see into the hallway while the resident was uncovered and exposed. Resident #2’s records showed admission with diagnoses including epilepsy, infection of the skin and subcutaneous tissue, an open wound of the left upper arm, and gastrostomy status. A recent MDS assessment documented a BIMS score of 11, indicating moderate cognitive impairment, and that the resident was dependent for toilet hygiene. The CNA later confirmed awareness that incontinence care required provision of privacy and that she had been trained and competency-checked on this requirement. For Resident #3, surveyors observed a CNA assisting the resident with eating while standing over the resident rather than sitting beside her, contrary to the facility’s feeding skills checklist and training. The DON intervened during the observation and instructed the CNA that staff were to sit next to residents while assisting with eating. The CNA stated she had forgotten to sit beside the resident. Resident #3’s records showed recent admission with diagnoses of cerebral infarction (stroke), anemia, and hemiplegia and hemiparesis affecting the right dominant side, and a baseline care plan indicating the resident was dependent for eating. Other staff interviews, including with a CNA supervisor, an LPN, the DON, and the Administrator, confirmed that staff were trained at least monthly on residents’ rights, respectful and dignified care, provision of privacy during incontinence care, and the expectation that staff sit beside residents when assisting with eating.
Failure to Maintain Accessible Call Light for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was maintained within reach as required by the facility’s feeding skills checklist. The skills checklist for feeding a resident specifies that staff must leave the call light within the resident’s reach after feeding. For Resident #2, surveyors observed on two separate occasions that the call light was not accessible. On one observation, the resident was awake in bed with a lunch tray on the overbed table, and the call light was found lying on the floor under the head of the bed. The resident stated he could use his call light but did not know where it was. On a subsequent observation, Resident #2 was again in bed with a lunch tray in front of him, and the call light was hanging behind the mattress at the head of the bed, out of his sight and reach. The resident again stated he could use the call light but did not know where it was. Record review showed the resident had epilepsy, an infection of the skin and subcutaneous tissue, an open wound of the left upper arm, gastrostomy status, and a BIMS score of 11 indicating moderate cognitive impairment. Staff interviews with CNAs, an LPN, the DON, and the Administrator confirmed that call lights were expected to be within residents’ reach and answered timely, and that staff had received in-service training and competency checks on leaving call lights within reach. The Administrator also confirmed there was no specific written policy regarding call light placement.
Failure to Provide Required Perineal Cleansing During Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to provide incontinent care in accordance with its own peri-care policy and professional standards of practice for a male resident who was dependent for toilet hygiene. The facility’s written policy for peri/incontinent care for male residents, revised in January 2023, required cleansing of the perineal area starting at the urethra and working outward, including washing and rinsing the penis, scrotum, inner thighs, and perineal area front and back, followed by thorough drying. Record review showed the resident had diagnoses including epilepsy, infection of the skin and subcutaneous tissue, an open wound of the left upper arm, and gastrostomy status, and a Quarterly MDS with a BIMS score of 11 indicating moderate cognitive impairment, with the resident assessed as dependent for toilet hygiene. On the observed date and time, CNA #1 provided incontinent care to this resident by removing a wet urine-soaked brief, changing the fitted sheet, and applying a clean, dry brief without cleansing the resident’s perineal area, front or back, contrary to facility policy. During a subsequent interview, CNA #1 acknowledged she had received in-service training and competency check-offs on peri-care and knew she was supposed to cleanse the perineal area but did not do so, stating she was nervous. Additional interviews with CNA #2 (CNA supervisor and scheduler), an LPN, the DON, and the Administrator confirmed that staff were trained using the Peri Care–Incontinent Care Skills Checklist and that proper incontinent care includes cleansing the perineal area, front and back, in addition to changing the brief. The failure to perform the required cleansing during incontinent care constituted the cited deficiency related to prevention of urinary tract infections.
Failure to Maintain Infection Control Practices During PEG Tube and Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program by not maintaining aseptic technique and not providing ordered dressing changes for residents with PEG tubes and a sacral pressure injury. Facility policies on infection control and clean dressing changes required wound care to be provided in a manner that decreases the potential for infection and cross-contamination, including removal of soiled dressings with gloves, discarding gloves, performing hand hygiene, and donning clean gloves before continuing care. The peri-care audit tool also required glove removal, hand hygiene, and re-gloving after peri-care. These standards were not followed during multiple observed care episodes. For one resident with a PEG tube and diagnoses including Alzheimer’s disease, functional quadriplegia, and gastrostomy status, surveyors observed the PEG tube site without a dressing and with a yellowish-brown substance beneath and around the external skin disk extending about one-fourth inch onto surrounding skin. A CNA and an LPN both confirmed there was no dressing in place and acknowledged the drainage at the site. The LPN stated PEG tube site care should be completed daily and as needed for increased drainage and acknowledged that, with no dressing and the amount of drainage present, there was no way to tell when the site was last cleaned. Record review showed a physician order, effective several months prior, for daily cleansing of the PEG tube stoma with normal saline, patting dry, and applying a dry drain dressing to avoid skin breakdown. For another resident with severe protein-calorie malnutrition and gastrostomy status, the PEG tube site was observed with thick brown, crusted substance beneath the external skin disk extending approximately one-half to three-fourths of an inch to the surrounding area. The resident reported the site had not been cleaned in about three days and later stated they might have to clean it themselves. Follow-up observations confirmed the site remained unclean with visible drainage, and an LPN and the DON both confirmed the presence of thick, brown drainage and that the site had not been cleaned in several days, despite an order for daily cleansing with soap and water, rinsing, patting dry, and leaving open to air or applying a dry dressing if drainage was present. In a separate observation involving a resident with a stage IV sacral pressure ulcer and severe cognitive impairment, a CNA provided peri-care for stool soiling, then immediately assisted with wound care using the same gloves worn during peri-care, without performing hand hygiene or changing gloves. The CNA, treatment nurse, DON, and ADON all acknowledged that hand hygiene and glove change should have occurred between peri-care and wound care and that this represented an infection control concern.
Failure to Maintain Clean Resident Rooms and Shower Facilities
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by its Resident Rights & Quality of Life Policy. For one resident, surveyors observed a bag of odorous soiled linens resting on the floor of the room, and the resident’s bed was made with a bedspread that had a football-sized hole exposing the mattress. The resident, who was cognitively intact with a BIMS score of 14 and had Type 2 Diabetes Mellitus, reported that it was not unusual for bags of soiled linens to be left on the floor and for bedding to be damaged. A CNA confirmed that soiled linens were commonly left in bags on the floor after morning care and that torn bedding should not be used, and later placed the bag of soiled linens on the resident’s furniture where his clean clothing was hanging. The resident remained upset the following day, and a dead roach was observed under his bed near the headboard. Additional deficiencies were identified in other resident rooms. One resident with End Stage Renal Disease and a severely impaired cognition (BIMS score of 5) reported that housekeeping did not clean under the bed; surveyors observed three large dead roaches under the bed, which remained there the following day. When the Housekeeping Supervisor later observed the room, five dead roaches were present under the bed, and he stated the area should not have been in that condition. Another resident, with a diffuse traumatic brain injury and a moderately impaired cognition (BIMS score of 10), reported frequently picking up and disposing of dead roaches himself because staff did not remove them, and a large dead roach was observed under his bed. The facility also failed to maintain a clean and sanitary north shower room. During a Resident Council interview, multiple cognitively intact and moderately impaired residents reported refusing to use the shower room due to cleanliness concerns, including observations of dirty clothing, feces, and residue on shower chairs and floors. A housekeeper stated that while she cleaned the shower rooms multiple times a day, CNAs were responsible for cleaning and sanitizing the shower room after each use and that she had observed occasions when CNAs failed to do so. A subsequent observation of the north shower room revealed soiled clothing, including a soiled brief, on a shower chair, a yellow fluid-like substance on the floor and shower chair, and a white powdery substance on the floor, with no staff present. The Social Services Assistant, DON, and Administrator each acknowledged that staff were expected to clean and sanitize the shower room after each use.
Ongoing Roach Activity Demonstrates Ineffective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program as required by its pest control policy dated 9/1/2014, which states the center will maintain an ongoing program to keep the building free of insects and rodents. Surveyors observed multiple instances of roach and insect activity in resident rooms and common areas. In one cognitively intact resident’s room, gnats were seen flying and a dead roach was later found under the bed near the headboard. Another resident’s room contained three large dead roaches under the bed on two consecutive days; this resident reported that roaches were regularly seen in the room, especially at night, crawling on the ceiling and falling onto him and his roommate, and that staff had been notified but he had not seen staff respond to assess or treat the issue. A third resident reported seeing roaches on the ceiling and under the bed and stated he often removed dead roaches himself because staff did not; a large dead roach was observed under his bed. A family member of another resident reported feeling it was necessary to bring her own roach spray due to concerns about roaches in the resident’s room and stated she was told she could not keep the spray in the room, expressing concern that the roach problem needed to be addressed. During a Resident Council meeting, two large roaches were observed crawling across the floor, and residents reported that roaches were commonly seen in rooms and common areas, including on walls, ceilings, and floors, particularly at night. The contracted pest control provider reported he provides monthly services, focusing on different areas each visit, primarily treating entry points and exterior areas, and stated he had not personally observed roaches and received only occasional complaints. Facility leadership, including the housekeeping supervisor, DON, and Maintenance Director, described expectations that staff report pest sightings and that pest control services are available monthly and as needed, but the ongoing presence of roaches and dead insects in resident rooms and common areas demonstrated that the pest control program was not effectively preventing or controlling pests.
Failure to Ensure Resident Access to Private Telephone Communication
Penalty
Summary
The facility failed to ensure a resident’s right to reasonable access to and privacy in the use of a telephone for communication. Facility policy on Resident Rights, revised December 2016, states that residents are guaranteed access to a telephone, mail, and email, and the ability to communicate in person and by mail, email, and telephone with privacy. Resident #1 was admitted on 12/18/24 with diagnoses including Sjogren syndrome, rheumatoid arthritis, chronic kidney disease, and morbid obesity. During an interview, the resident reported that she had dropped and broken her personal cellular telephone, which she had used for private communication, and that the facility did not have any telephone that was convenient for her to use privately. She stated that no staff had offered her the use of a staff office or any other mechanism for private communication, and she was upset because she relied on telephone contact with her significant other, who had cancer and was unable to visit. Observations and staff interviews confirmed the lack of accessible, private telephone options for residents on South Hall. An observation on the 100 Hall revealed there was no cordless telephone available for resident use. The DON confirmed that the facility did not have a method to provide residents on South Hall with private communication without first making arrangements or an appointment to use a staff office, and that the cordless telephones in the facility did not have sufficient range to reach South Hall. The SSD confirmed there were no cordless telephones at the South Hall nurses’ station that could be taken to residents’ rooms and acknowledged that Resident #1’s cell phone had been broken and sent out for repair. The Administrator also confirmed that residents on South Hall did not have a method for private communication without prior arrangements and acknowledged that access to private communication is a guaranteed resident right.
Failure to Provide Adequate ADL Assistance for Personal Hygiene
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) to maintain personal hygiene for one resident who was dependent on staff for care. Facility policy on ADLs, revised March 2018, stated that residents unable to carry out ADLs independently would receive services necessary to maintain good grooming and personal and oral hygiene. Record review showed the resident was admitted with heart failure, chronic kidney disease, and hypertension, had a BIMS score of 12 indicating moderate cognitive impairment, was always incontinent of bowel and bladder, and required substantial/maximal assistance for personal hygiene and was dependent for toilet hygiene. A complainant reported that the resident had expressed difficulty getting staff to provide assistance with ADLs. During an observation and interview with the resident, accompanied by an LPN, the resident reported ongoing difficulty obtaining assistance with ADLs. The surveyor observed that the resident had ten long, dirty fingernails protruding 3.0 to 3.5 millimeters past the fingertips, with a black substance beneath all fingernails; the resident stated they needed cleaning and cutting and were too long. The LPN described the fingernails as too long and dirty, confirmed that nursing staff were responsible for checking fingernails daily during care and weekly during body audits, and acknowledged that staff were responsible for providing fingernail care as part of ADLs. The LPN also confirmed that long, dirty, unkempt fingernails had the potential to cause damage or scratches to the resident’s skin. The DON stated she was not aware of any complaints from the resident but confirmed her expectation that ADLs for residents dependent on staff for personal hygiene would be maintained and provided as needed, and that licensed nurses trimmed fingernails for some residents while any nursing staff could clean under fingernails. The Administrator confirmed that personal hygiene and grooming were part of resident ADLs and were expected to be provided for all dependent residents.
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