Diversicare Of Eupora
Inspection history, citations, penalties and survey trends for this long-term care facility in Eupora, Mississippi.
- Location
- 156 E Walnut Ave, Eupora, Mississippi 39744
- CMS Provider Number
- 255117
- Inspections on file
- 20
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Diversicare Of Eupora during CMS and state inspections, most recent first.
An LPN repeatedly documented PRN opioid pain medications for multiple residents at identical, preset times during routine med passes, rather than based on individualized pain assessment and actual administration times. One cognitively intact resident with a history of stroke consistently denied pain and stated he did not take pain medication, while other staff confirmed he did not request analgesics; however, the LPN documented frequent Norco administration and high pain scores for him, and later admitted giving medication without his consent and falsely recording pain levels. Review of MARs and narcotic logs for 13 residents showed large clusters of PRN Norco and oxycodone entries at the same times across different rooms, and the LPN acknowledged that the records did not accurately reflect real administration times and that she sometimes entered pain scores without asking residents, contrary to facility policy and professional standards.
Two cognitively intact residents experienced undignified care when staff failed to provide timely toileting assistance and used disrespectful communication. One resident, with multiple chronic conditions, reported that a CNA questioned her need to use the bathroom at night and later left her sitting on the toilet for about 30 minutes until she used the bathroom call light, after which the CNA stated she had to make her rounds. Another resident with cerebral palsy, incontinent and fully dependent on staff for toileting and hygiene, was found by a family member with the call light sounding, wet, and with three soiled, spaghetti-covered towels left on her chest from lunch; when a CNA entered, she removed the towels and told the resident she was "just showing out" because her sister was present. The DON and nursing staff interviews confirmed expectations that residents be treated with dignity and respect and receive timely toileting.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Staff failed to immediately report an incident where an LPN used profanity and applied force to a resident. Two CNAs who witnessed the event delayed reporting, assuming others had done so, and another LPN did not recognize the behavior as abuse. The incident was reported to the State Agency but not to the Board of Nursing, contrary to policy, despite staff having received recent training on abuse reporting.
A resident with insulin-dependent diabetes and a diabetic foot ulcer was admitted without orders for insulin or wound care, despite repeatedly informing staff that her insulin had been discontinued in error and requesting provider notification. Nursing staff did not obtain clarification or new orders for insulin or wound care, and the resident self-administered insulin without assessment or documentation. Wound care was delayed and not documented until several days after admission, contrary to facility policy requiring prompt intervention and physician notification.
The facility failed to resolve grievances related to food quality and bed linen changes for several residents. Despite repeated complaints in resident council meetings, issues such as lack of food variety, poor taste, and infrequent linen changes were not addressed. The Administrator and Dietary Manager were aware of the complaints but did not document or follow up effectively, leading to ongoing resident dissatisfaction.
The facility failed to provide palatable, attractive, and appropriately heated meals to residents, leading to dissatisfaction among several residents. Complaints included cold, flavorless, and improperly cooked food, with limited meal options that did not meet dietary needs. Despite raising these issues with the Dietary Manager, the concerns remained unaddressed.
A resident with an overactive bladder and other medical conditions was denied assistance with toileting due to staff being occupied with meal tray distribution. Staff interviews revealed a misunderstanding of policy, believing they could not assist residents during mealtimes due to cross-contamination concerns. The DON acknowledged the resident's right to use the bathroom but needed to review the policy.
The facility failed to implement and develop care plans for three residents, resulting in deficiencies in their care. A resident's nail care was neglected, another resident did not have a care plan for necessary leg brace use due to communication failures, and a third resident lacked a care plan for Binge Eating Disorder after readmission. Staff interviews confirmed these oversights.
A resident with diabetes and moderate cognitive impairment did not receive necessary nail care, resulting in long nails that caused self-scratching. Facility staff acknowledged that diabetic nail care was not scheduled or documented, although it was expected to be performed as needed.
A facility failed to monitor a resident with a new diagnosis of Binge Eating Disorder. Despite the resident's frequent requests for snacks and taking food from carts, staff were unaware of the diagnosis. The Medication Administration Record lacked monitoring for this behavior, focusing on other issues. The DON confirmed the absence of monitoring, noting its importance for managing the resident's condition.
A facility failed to implement dietary recommendations for a resident receiving enteral nutrition via PEG tube. The RD's recommendations to adjust tube feeding and water flushes were not acted upon due to a communication lapse. The DON did not notice the recommendations in the email, and the LPN did not act on them without instruction. Consequently, the resident's nutritional needs were not met.
The facility inaccurately completed Section N of the MDS for two residents, leading to incorrect documentation of anticoagulant and antibiotic medications. One resident was documented as receiving anticoagulants but was on antiplatelet medication, while another was documented as receiving anticoagulants but was on antibiotics. These errors were confirmed by the MDS Coordinator and attributed to a remote MDS worker.
A resident with limited mobility did not receive necessary services to maintain or improve mobility due to staff failing to apply leg braces as per the therapy plan. The resident's therapy was discontinued, and the facility did not enter the order for brace application into the system, resulting in no tasks for staff to follow. Miscommunication and misunderstanding of the agreed schedule led to the resident not wearing the braces, impacting his mobility improvement efforts.
A resident's inhalant medication was left unsecured at the bedside by an LPN after administration, contrary to the facility's policy requiring medications to be stored in a locked compartment. The resident, who has COPD and Asthma, was assessed for supervised medication administration. The DON confirmed the risk posed by the unsecured medication.
The facility failed to provide bedtime snacks to residents, including those with diabetes, as snacks were left at the nurse's desk and not distributed. Mobile residents could retrieve snacks, but those who were not mobile were left without. Staff interviews confirmed the issue, with the Administrator unaware and the Dietary Manager stating that aides were responsible for distribution.
Clustered False Documentation and Non-Individualized PRN Opioid Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure licensed nursing staff followed professional standards of practice for accurate, individualized assessment and documentation of PRN opioid pain medications for 13 residents on one medication cart. Facility policies required medications to be administered as prescribed, in accordance with good nursing principles, and clinical records to be complete and accurate for continuity of care, including consistent evaluation, management, and documentation of pain. Despite these requirements, record review of January and February 2026 MARs and controlled substance records showed repetitive, clustered documentation of PRN narcotic administration at identical times for multiple residents, which did not reflect individualized assessment or real-time documentation. One resident reported concerns that an LPN attempted to administer medications without allowing her to visually verify them, that she questioned whether her Norco was present, and that she did not experience expected pain relief; on one occasion she observed a pill that did not resemble her usual Norco and was told it was broken. Resident #9 was a cognitively intact resident with hemiplegia and hemiparesis following cerebral infarction, whose MDS indicated frequent pain affecting sleep and daily activities. However, during interviews he consistently denied pain, stated he did not take pain medication, and reported refusing pain medication when offered. Other LPNs confirmed that he did not usually take pain medication and had never reported pain or requested PRN analgesics from them. In contrast, MARs and the controlled substance inventory showed that one LPN (LPN #3) documented Norco administration to this resident at highly consistent times (around 7:01 AM, 12:31 PM, and 6:31–6:49 PM) and recorded pain scores of 8–9 on her shifts, while other shifts documented pain scores of zero. LPN #3 later admitted she did not ask this resident about pain, administered medication without his consent, and falsely documented high pain scores. Across all 13 residents with PRN opioid orders (primarily Norco and one resident with oxycodone), MAR review revealed a pattern of clustered documentation by LPN #3, with large groups of residents recorded as receiving PRN pain medication at the exact same times on multiple dates. In January and February, PRN doses were repeatedly documented at standardized times such as 7:01 AM, 11:01 AM, 12:31 PM, 3:01 PM, and clustered evening times between 6:31 PM and 6:49 PM, sometimes for as many as 12 residents at once. LPN #3 acknowledged in a telephone interview that she administered all PRN pain medications during routine med passes and intentionally selected one set time for all residents so they could receive subsequent doses based on order frequency, and that the medical records did not accurately reflect actual administration times. She further admitted she did not always ask residents about their pain, sometimes entered pain levels without asking them, and recognized that this practice and her documentation were not in accordance with nursing standards. The DON confirmed that review of the 13 residents’ MARs showed a pattern of documentation inconsistencies related to this nurse, and the nurse had a history of prior medication documentation and narcotic handling issues identified through progressive discipline and consultant pharmacist review.
Failure to Provide Dignified, Timely Toileting and Respectful Care
Penalty
Summary
The deficiency involves failure to ensure residents were treated with dignity and respect by providing timely toileting assistance and by using respectful communication. One resident, cognitively intact and dependent on staff for assistance, reported that around 11:00 PM she activated her call light to request help to the bathroom. CNA #1 responded by questioning whether someone had already taken her to the bathroom and, after being informed the resident had been asleep and needed to go at that time, did assist her. Later, at approximately 3:00 AM, the same resident again required toileting assistance. Although CNA #1 assisted her to the toilet, the resident stated she was left sitting there for about 30 minutes without supervision. When CNA #1 did not return, the resident activated the bathroom call light, and upon returning, CNA #1 told her, "I told you I was coming back. I had to make my rounds." The resident reported telling CNA #1 she could not sit on the toilet for that length of time and should not have to remain there for an extended period, and further reported she notified the night nurse, who said the issue would be reported to RN #2. RN #2 later stated she was not made aware of any complaints or concerns about this resident on Monday morning. The DON acknowledged CNA #1 could be gruff in tone, had multiple prior write-ups, including for leaving a resident on the toilet longer than appropriate, and confirmed the expectation that residents receive timely toileting. A second cognitively intact resident with cerebral palsy, always incontinent of bladder, frequently incontinent of bowel, and dependent on staff for toileting and personal hygiene, was also involved. A family member reported arriving shortly after 1:00 PM and finding the resident’s call light sounding because she was wet and needed to be changed, with three soiled towels from lunch, covered in spaghetti, left on her chest. The family member stated the call light had been going off for some time before day-shift CNA #5 entered the room, removed the soiled towels, and said to the resident, "You're just showing out because your sister is here." CNA #5 later confirmed that dirty towels had been left on the resident’s chest and that the family was upset, and stated she left the room to allow time for the situation to deescalate. The DON confirmed her expectation that all residents have the right to be treated with dignity and respect.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Immediately Report and Recognize Abuse Allegations Involving Licensed Staff
Penalty
Summary
The facility failed to ensure that all allegations of abuse were immediately reported to the State Agency and the appropriate licensing board, as required by facility policy and regulations. Specifically, an incident involving a licensed nurse using profanity and applying force to a resident was witnessed by two CNAs, but both delayed reporting the incident until the following day, assuming another staff member had already reported it. Additionally, another LPN who overheard the use of profanity did not consider it abuse and did not report the incident. The incident was eventually reported to the State Agency, but not to the Board of Nursing, as the facility did not substantiate the abuse despite having statements from both CNAs. Interviews with staff confirmed a lack of immediate reporting and a failure to recognize the incident as abuse. The Administrator and DON acknowledged that staff did not follow the policy requiring immediate reporting of abuse allegations and that the required notification to the Board of Nursing was not made. Record review showed that all involved staff had attended a recent in-service training on abuse and neglect, which emphasized the importance of immediate reporting of any suspicion of abuse.
Failure to Provide Resident-Centered Care and Timely Physician Notification for Insulin and Wound Care
Penalty
Summary
The facility failed to identify and provide needed care and services that were resident-centered and in accordance with the resident's preferences, goals for care, and professional standards of practice for one resident. Upon admission, the resident, who had a history of insulin-dependent diabetes mellitus and a diabetic ulcer, informed staff that her insulin had been discontinued in error at the hospital and requested that the provider be contacted to clarify and reinstate her insulin orders. Despite repeated requests from the resident over several days, the nursing staff did not contact the provider for clarification or obtain new orders for insulin or wound care. The resident continued to self-administer her own insulin using a personal insulin pen, without an assessment for self-administration, and without facility orders or documentation for this medication. Additionally, the resident had a diabetic ulcer on her toe that was covered with a dressing upon admission. She requested wound care and dressing changes, but was told there were no orders for wound care. Although the dressing was changed by nurses on two occasions, the resident was unsure of the treatment used, and there was no documentation of wound care orders or treatments until several days after admission. The RN Treatment Nurse did not assess the wound until several days after admission, at which point a new wound care order was obtained from the Nurse Practitioner. Documentation revealed that the facility's policy required immediate implementation of resident-specific interventions and prompt notification of the physician when an open area was identified, which was not followed in this case. Interviews with facility staff, including the DON and RN Treatment Nurse, confirmed that the resident's requests for insulin and wound care were not addressed in a timely manner, and that appropriate notifications to providers were not made. The DON acknowledged that the resident had the right to necessary treatments and medications, and that the facility failed to obtain orders for both wound care and insulin, resulting in a lack of appropriate treatment and care according to the resident's needs and preferences.
Unresolved Grievances on Food Quality and Linen Changes
Penalty
Summary
The facility failed to adequately address grievances related to food quality and bed linen changes for several residents. Despite the facility's policy to actively seek resolution and keep residents informed, grievances from five residents regarding food concerns and infrequent linen changes were not resolved. Interviews with residents and staff revealed ongoing dissatisfaction with the food, including lack of variety, poor taste, and inadequate vegetarian options. Residents reported these issues repeatedly in resident council meetings, but no effective action was taken to address their concerns. The facility's Administrator and Dietary Manager were aware of the food complaints, yet failed to document or follow up on the grievances. The Administrator acknowledged the residents' dissatisfaction but did not complete a formal grievance process. The Dietary Manager claimed to have addressed the concerns but lacked documentation to support this. Additionally, the Social Services staff did not complete grievances for food complaints, believing them to be outside their responsibility. Residents also expressed concerns about the infrequency of bed linen changes, which were reportedly only done every two weeks or during deep cleaning. Despite these issues being raised in resident council meetings, there was no documentation or evidence of corrective actions taken. The facility's failure to resolve these grievances highlights a lack of effective communication and follow-up on resident concerns, leading to ongoing dissatisfaction among the residents.
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and served at a safe and appetizing temperature for seven of the twelve residents sampled. Residents reported issues such as food being cold, lacking flavor, and not being cooked thoroughly. For instance, one resident mentioned receiving cornbread that was too hard to chew, while another resident complained about the lack of gravy on rice, which was a personal preference that was not accommodated despite discussions with the Dietary Manager. Several residents expressed dissatisfaction with the quality and variety of meals provided. One resident, who is diabetic, noted that the meal options were not suitable for their dietary needs, as they included multiple starchy items. Another resident, who is a vegetarian, reported a lack of appropriate meal options and described the food as disgusting and lacking seasoning. Additionally, there were instances where residents received incorrect meal items, such as being served a chicken salad sandwich instead of the requested tuna salad. Observations by the State Agency confirmed the residents' complaints, noting that sample trays from the kitchen contained food that was not warm and lacked flavor. The Dietary Manager acknowledged receiving complaints from residents about the food quality and confirmed that there were ongoing concerns. Despite these issues being raised in resident council meetings and directly with the Dietary Manager, the problems persisted, indicating a failure to address the residents' dietary needs and preferences adequately.
Failure to Assist Resident with Toileting During Mealtime
Penalty
Summary
The facility failed to honor a resident's right to a dignified existence and self-determination when a staff member refused to assist a resident with toileting. On one of the survey days, a resident expressed an urgent need to use the bathroom after returning from an appointment. Despite using the call light to request assistance, the resident was informed by a Registered Nurse (RN) that assistance could not be provided because staff were occupied with passing meal trays. The RN and the Director of Nursing (DON) did not return to assist the resident, leaving the resident in distress. Interviews with staff, including the DON and Certified Nurse Aides (CNAs), revealed a misunderstanding of facility policy, with staff believing they were not allowed to assist residents with toileting during mealtimes due to concerns about cross-contamination. The DON acknowledged the resident's right to use the bathroom when needed but indicated a need to review the policy. The resident involved was cognitively intact, with medical diagnoses including overactive bladder, Type 2 Diabetes Mellitus, and heart failure.
Failure to Implement and Develop Care Plans for Residents
Penalty
Summary
The facility failed to implement and develop care plans for three residents, leading to deficiencies in their care. Resident #41's care plan included daily nail care, but observations revealed that the resident's fingernails were long and untrimmed, indicating that the care plan was not followed. Interviews with staff confirmed the oversight. Resident #51 required leg braces to aid mobility, but no care plan was developed for their use. The resident reported not wearing the braces since therapy ended, and staff interviews revealed a communication failure in entering therapy orders into the system, resulting in the absence of a care plan. Resident #113, who was diagnosed with Binge Eating Disorder, did not have a care plan addressing this condition. The oversight was confirmed during interviews with the RN Director of Clinical Services and the DON, who acknowledged that the diagnosis was not incorporated into the care plan upon the resident's readmission. This lack of a care plan for behavior monitoring was attributed to a failure in updating the resident's care needs after hospital discharge.
Failure to Provide Diabetic Nail Care
Penalty
Summary
The facility failed to provide adequate personal hygiene care for a resident, specifically in the area of nail care. The resident, who is diabetic and moderately cognitively impaired, expressed the need for her nails to be cut as they were long and causing her to scratch herself. During an observation and interview, it was noted that the resident's nails were approximately one-half inch in length, indicating they had not been trimmed in a significant amount of time. Interviews with facility staff, including an LPN and the DON, revealed that diabetic nail care was not scheduled or documented in the Treatment Administration Record (TAR) but was expected to be performed as needed. The LPN confirmed that nail care for diabetic residents should be conducted by a nurse due to the potential for skin injury. Despite this understanding, the facility did not have a formal process in place to ensure regular nail care for diabetic residents, leading to the oversight in the resident's personal hygiene.
Failure to Monitor Binge Eating Disorder in Resident
Penalty
Summary
The facility failed to provide appropriate behavioral monitoring and interventions for a resident with a new diagnosis of Binge Eating Disorder. The resident, who was admitted with Type 2 Diabetes and Schizophrenia, was readmitted with the additional diagnosis of Binge Eating Disorder. Despite this, the facility did not implement monitoring for this behavior. Interviews with staff, including CNAs and an RN, revealed that they were unaware of the resident's Binge Eating Disorder diagnosis, although they noted the resident's frequent requests for snacks and instances of taking food from carts. The Medication Administration Record did not include monitoring for Binge Eating Disorder, focusing instead on other behaviors such as hallucinations and delusions. The Director of Clinical Services and the DON confirmed the absence of monitoring for the disorder, acknowledging that the diagnosis was not picked up upon the resident's return from the hospital. The DON noted that behavior monitoring is crucial for timely management, especially given the resident's severe cognitive impairment and the potential impact on blood sugar levels due to binge eating.
Failure to Implement Dietary Recommendations for Enteral Nutrition
Penalty
Summary
The facility failed to address dietary recommendations for a resident receiving enteral nutrition through a PEG tube. The Registered Dietician (RD) assessed the resident and recommended changes to the tube feeding and water flushes to meet the resident's nutritional needs. The RD sent these recommendations to the interdisciplinary team via email. However, the Director of Nursing (DON) did not notice the recommendations in the email, and the Licensed Practical Nurse (LPN) did not act on them as she was not instructed to do so by the DON. Consequently, the necessary changes to the resident's nutritional plan were not implemented. The resident, who was admitted with diagnoses including cerebral infarction and gastrostomy care, continued to receive inadequate nutrition as per the existing orders. The RD's recommendations, which included increasing the caloric intake and adjusting the water flushes, were not communicated to the supervising physician for approval and activation in the electronic medical record. This oversight resulted in the resident's nutritional needs not being met during their stay at the facility.
Inaccurate MDS Medication Coding for Two Residents
Penalty
Summary
The facility failed to accurately complete Section N of the Minimum Data Set (MDS) assessment for two residents, leading to discrepancies in medication documentation. For Resident #46, the MDS indicated that the resident received anticoagulant medication for seven days during the observation look-back period. However, a review of the Electronic Medication Administration Record (eMAR) revealed that the resident did not receive any anticoagulant medication during this period. Instead, the resident was on antiplatelet medication, which was incorrectly coded by a remote MDS worker. The resident was admitted with diagnoses including Peripheral Vascular Disease, Tachycardia, and Atherosclerotic heart disease. Similarly, for Resident #96, the MDS inaccurately documented that the resident received anticoagulant medication for seven days, while the eMAR showed no such medication was administered. Instead, the resident was on an antibiotic, Macrobid, which was not coded in the MDS. The resident's admission diagnoses included Cerebral infarction and Hyperlipidemia. The MDS Coordinator confirmed these coding errors during an interview, attributing them to a remote MDS worker's mistake.
Failure to Apply Leg Braces for Resident with Limited Mobility
Penalty
Summary
The facility failed to ensure a resident with limited mobility received appropriate services and assistance to maintain or improve mobility. The resident, who was supposed to wear leg braces twice a day to improve mobility, reported that staff had not applied the braces since his therapy was discontinued. The braces were observed to be unused in the resident's room, and interviews confirmed that the staff had not followed through with the plan of care established by the therapy team. The Physical Therapist confirmed that the resident's therapy was discontinued, and a plan was in place for the resident to continue using the braces. However, the Director of Nursing (DON) was unaware of the issue and noted that there was no active order for the braces in the system. The failure to enter the order into the system resulted in no tasks being assigned to staff, leading to the resident not receiving the necessary range of motion services. Interviews with staff revealed a lack of communication and understanding of the agreed-upon schedule for brace application. A Certified Nursing Assistant (CNA) reported that the resident refused to wear the braces when offered at an incorrect time, which was not aligned with the resident's preferences. The Physical Therapy Assistant confirmed that the facility staff did not apply the braces as required, and the resident expressed gratitude for the resolution of the issue, hoping the new system would prevent future occurrences.
Improper Storage of Inhalant Medication
Penalty
Summary
The facility failed to store an inhalant medication in a locked storage compartment, as observed during a medication administration for a resident. The incident involved a respiratory inhaler, which was left on the resident's overbed table by an LPN after administration. The resident confirmed that the nurse had brought the inhaler for use earlier and left it at the bedside. The LPN admitted to forgetting to return the inhaler to the locked medication cart, despite being aware of the facility's policy on medication storage. The resident involved had a history of Chronic Obstructive Pulmonary Disease and Asthma and was cognitively intact, as indicated by a BIMS score of 15. The resident was assessed for medication administration with supervision, not independent administration. The Director of Nursing confirmed that the improper storage of medication posed a risk for unauthorized access. The facility's records showed an active order for the inhaler, which was administered by the LPN on the day of the observation.
Failure to Provide Bedtime Snacks to Residents
Penalty
Summary
The facility failed to provide residents with a bedtime snack, as revealed during a resident council meeting. Six residents, including those with diabetes, reported not receiving snacks at night. The facility's snack program indicated that snacks were delivered to the nurse's desk between 7:30 pm and 8:00 pm, but they were not distributed to residents. Instead, residents who were mobile could retrieve snacks from the desk, leaving those who were not mobile without access. This practice resulted in a 'first come, first served' situation, disadvantaging residents who could not reach the desk. Interviews with staff, including the Administrator and Dietary Manager, confirmed the issue. The Administrator was unaware of the problem and noted that the kitchen had stopped sending individual snacks with residents' names. The Dietary Manager stated that bulk snacks were sent to the nurse's desk, and aides were responsible for distribution. A Registered Nurse working the night shift confirmed that residents often had to ask for snacks at the desk. The report highlights the facility's failure to ensure that all residents, particularly those with diabetes, received necessary bedtime snacks to prevent low blood sugar levels.
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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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