Diversicare Of Southaven
Inspection history, citations, penalties and survey trends for this long-term care facility in Southaven, Mississippi.
- Location
- 1730 Dorchester Dr, Southaven, Mississippi 38671
- CMS Provider Number
- 255109
- Inspections on file
- 30
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 3 (1 serious)
Citation history
Health deficiencies cited at Diversicare Of Southaven during CMS and state inspections, most recent first.
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.
A cognitively impaired resident with dementia and documented wandering and elopement risk exited the facility unnoticed after following a visitor out the front entrance. Nursing staff had last seen the resident walking the halls after lunch, but when the resident was no longer observed, an LPN initiated a missing resident code and staff began searching. The receptionist, who was responsible for monitoring the entrance and using an elopement book with photos and information on at-risk residents, stated she had not been informed that this resident was an elopement risk and did not recognize her as a resident when she followed a visitor outside. The elopement book contained no information on this resident, and the door alarm did not sound when they exited; maintenance and the administrator later confirmed video showed the receptionist turning off the alarm. The resident, who later reported she followed others because she did not want to be left alone, was found by staff in a nearby subdivision after leaving the building.
A resident admitted with essential HTN, paroxysmal A-fib, and rheumatoid arthritis did not receive three ordered medications—terazosin at HS, dabigatran twice daily at HS, and morphine sulfate twice daily—on the night of admission. The eMAR showed these doses coded as not given, and the only progress note entry stated "awaiting medications" without further documentation that they were obtained or administered. Facility protocol required checking the E Kit, contacting the pharmacy or backup pharmacy, notifying a supervisor, and, if delays exceeded four hours, contacting the MD, but staff did not follow these steps. An LPN and the DON confirmed that the medications were not administered and that the established protocol for unavailable medications was not implemented.
A resident with dementia and impaired lower extremity range of motion was improperly transferred by a CNA using a stand-pivot method instead of the required total lift with a medium yellow sling. This resulted in the resident being lowered to the floor and later diagnosed with a fracture above a previous joint replacement. The CNA admitted to not checking the Kardex for updated transfer instructions, leading to the resident's injury and hospitalization.
A resident with dementia and impaired lower extremity ROM was injured when a CNA used an incorrect transfer method, contrary to the care plan requiring a total lift and two staff members. The CNA did not consult the Kardex, leading to the resident's fall and subsequent fracture.
The facility inaccurately submitted staffing data into the PBJ system for the first quarter of 2025 due to unresolved issues with their payroll system. Late clock-ins and shifts crossing midnight were automatically transferred to the next shift without manual correction, leading to discrepancies in reported staffing data. The Administrator confirmed that the facility had not experienced low staffing, but the payroll system's inaccuracies affected the reported hours.
The facility failed to securely store hazardous cleaning chemicals on two housekeeping carts. One cart was found unlocked with chemicals accessible, and another had chemicals stored outside the locked cart due to a lack of a key. Staff were unaware of the locking issues, and the chemicals posed potential hazards, including severe skin burns and eye damage.
The facility failed to implement proper infection prevention and control practices for residents on Enhanced Barrier Precautions (EBP) and contact isolation. Staff did not wear gowns during wound and catheter care for two residents, despite EBP signage. Additionally, a resident on contact precautions for C. diff lacked biohazard containers, and ineffective cleaning products were used. These oversights were acknowledged by staff and confirmed by the Infection Preventionist and Housekeeping Supervisor.
The facility failed to ensure call lights were within reach for two residents, limiting their ability to request assistance. One resident's call light was wrapped around the bed rail, while another's was found inside a closed drawer and later on the floor. Staff confirmed the oversight, and the DON emphasized the importance of call light accessibility for resident safety. The residents involved had conditions such as blindness, end-stage renal disease, and hemiplegia.
The facility failed to maintain a safe and homelike environment for several residents, with issues such as broken furniture, mice droppings, leaking air conditioners, and malfunctioning equipment going unaddressed. These deficiencies compromised the safety and comfort of the residents, as maintenance and housekeeping concerns were not reported or resolved in a timely manner.
The facility failed to implement care plans for several residents, leading to deficiencies in their care. A resident with a self-care deficit had poor oral hygiene due to neglect of daily oral care. Two residents with ADL deficits had unclean and untrimmed fingernails, indicating a lack of proper grooming. Another resident with end-stage renal disease exceeded fluid restrictions due to inadequate monitoring and documentation. These failures were confirmed by staff and the DON.
The facility failed to provide adequate ADL care for three residents dependent on staff assistance. A resident had poor oral hygiene with a thick white substance on their teeth, while two residents had long, jagged fingernails with a brown substance underneath. Despite staff acknowledging the need for care, these deficiencies were observed, with one resident expressing dissatisfaction and another at risk of skin breakdown or infection.
A facility failed to secure electronic health records, leading to a privacy breach for two residents. An LPN left a medication cart unattended with residents' EMARs visible, exposing their personal information. The LPN and DON acknowledged the oversight, confirming it as a privacy violation.
A medication cart was left unlocked and unattended in the [NAME] Wing, with a medication cup containing six pills on top. An LPN admitted to leaving the cart unsecured while assisting with moving a bed. The facility's policy requires medication carts to be locked and secure when not in use, as confirmed by the DON.
A facility failed to document and obtain physician orders for a resident's PICC line care. An RN flushed the PICC and started an antibiotic infusion without an order, and the EMAR lacked documentation for these actions. This was confirmed by another RN and the DON. The resident was admitted for aftercare following knee joint prosthesis explantation.
A resident's dresser drawers were found to contain mice droppings, indicating a failure in the facility's pest control program. The issue was reported by the resident's husband and confirmed by a CNA and RN, who expressed concerns about contamination risks. The Maintenance Supervisor received a work order about the problem, but the facility's pest control policy was not effectively implemented.
A facility failed to accurately monitor and document fluid intake for a dialysis resident with a one-liter fluid restriction, leading to the resident exceeding the limit on multiple days. Inconsistent documentation by nursing staff, including an LPN and oversight by the DON, contributed to the inability to determine adherence to the restriction.
A resident's wound vac dressing was not changed as ordered, leading to foam adhering to the wound bed. The dressing was supposed to be changed every Monday and Thursday, but it was not changed from 4/1/2024 to 4/10/2024. This resulted in complications that required debridement to remove the adhered foam fragments.
A facility failed to implement an elopement risk plan for a resident with a history of wandering, leading to the resident exiting the facility unsupervised. The resident's care plan included checking the wander guard every shift, but records showed this was not consistently done. The resident was found off the facility grounds and returned by staff.
A resident identified as an elopement risk exited the facility unnoticed due to a kitchen door not being properly closed and locked. The resident was found talking to the police at a nearby apartment complex and was returned to the facility uninjured. The kitchen area lacked a wander guard alarm system, and no staff were assigned to monitor that area late at night.
The facility failed to provide a safe, clean, and homelike environment, with damaged floors, dirty halls, and a lack of clean linens. A resident was found without proper bedding in cold weather, and the facility's shower room had been broken for two months. Housekeeping and maintenance issues were prevalent, with unclean resident rooms and garbage piling up in the biohazard room. Staff and residents expressed ongoing concerns about the facility's cleanliness and safety.
A resident was found lying on a bare mattress with no sheets or bedspread, covered only by a small throw, while the window was open, and the outside temperature was 38 degrees. Staff confirmed the lack of clean linens and blankets and the unnecessary opening of the window. The Administrator and DON acknowledged the resident should have had proper bedding and the window should not have been open in such cold weather.
The facility failed to implement comprehensive care plans for three residents requiring assistance with ADLs. One resident was found disheveled and unshaven, another had to wait up to eight hours for toileting assistance, and a third mainly received bed baths instead of showers. The DON confirmed that staff were not adhering to care plans, resulting in inadequate care.
The facility failed to provide sufficient staff, resulting in inadequate assistance with bathing, grooming, and personal hygiene for three residents. Staff reported reduced night shift staffing, making it difficult to provide timely care. Interviews confirmed the staffing issues, with one LPN stating the workload was overwhelming and residents not receiving showers as they should. The DON acknowledged some staff were not meeting basic care expectations, and the Workforce Manager admitted to insufficient training in scheduling.
The facility failed to ensure that call lights were functioning in all resident rooms, as evidenced by non-functioning call lights in the rooms of two residents. Observations and interviews confirmed that the call lights did not make any noise to alert staff, and maintenance was not aware of the issues. Both residents involved were cognitively intact.
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 Implement Elopement Protections Allows Cognitively Impaired Resident to Exit Unnoticed
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and implement its elopement prevention system for a resident identified as an elopement and wandering risk. The resident was admitted with diagnoses including unspecified moderate dementia with behavioral disturbance and wandering, and had a BIMS score of 0, indicating severe cognitive impairment. On admission, the resident was assessed as being at risk for elopement, and documentation noted that a wander guard was in place. The facility’s clinical care system guidelines required that residents at risk for elopement have individualized interventions documented on the care plan and caregiver guide, a photograph taken, and their information placed in a central elopement information system, such as an elopement book at the nurse’s station or reception. On the day of the incident, nursing staff, including an LPN and CNAs, were aware that the resident wandered and was at risk for elopement and had last observed her walking the halls shortly after lunch. Around 1:00 PM, the LPN noticed the resident was no longer in the hallway and directed CNAs to check the resident’s room. When the resident was not found, the nurse initiated a missing resident code and staff began searching. Another resident reported seeing a lady in pink walking outside her window, prompting staff to search outside the building. The resident later confirmed in an interview that she had gone outside after following others because she did not want to be left alone when they left the table where she had been sitting. At the front entrance, the receptionist allowed a visitor to exit while a woman in pink followed the visitor out. The receptionist stated she was not aware that this individual was a resident and did not know she was at risk for wandering or elopement. She reported that there was an elopement book at the desk that should contain pictures and information on residents at risk, but she had not been notified about this resident and there was no information about her in the book. The receptionist also stated that the door alarm did not sound when she let the visitor and the woman in pink out, and that the alarm had been intermittently activating earlier in the day without residents present. Maintenance later reported that video footage showed the receptionist turning off the alarm after the visitor and the resident exited. The administrator confirmed that her review of the video showed the receptionist turning off the alarm and verified that the elopement book did not contain a picture or information regarding the resident’s elopement risk at the time of exit. The resident was determined to have exited the facility at approximately 1:08 PM and was located by staff about 0.4 miles away at 1:33 PM.
Removal Plan
- Implemented the elopement guideline.
- Completed an immediate room-to-room audit of all residents to assure all were safe.
- Returned Resident #1 safely to her room.
- Checked Resident #1’s wander guard for functionality upon return and confirmed it was functioning as designed.
- Performed a full body audit/assessment of Resident #1 immediately upon return with no negative findings.
- Placed Resident #1 on 1:1 supervision pending psychiatric consultation.
- Placed a request for psychiatric consultation for Resident #1.
- Planned that following removal of 1:1 supervision, Resident #1 would have visual observations every 30 minutes for 24 hours and continued as needed.
- Reviewed and updated Resident #1’s plan of care to reflect elopement risk.
- Checked all doors for proper function and operation and confirmed all doors were functioning properly.
- Notified the Medical Director.
- Notified Resident #1’s resident representative.
- Completed a 100% audit of all residents identified for elopement risk to ensure placement and functioning of the wander guard system.
- Completed an audit of elopement books on all units and at reception to ensure pictures and care plans were present for all at-risk residents.
- Completed elopement drills on all shifts.
- Educated the Receptionist on elopement guidance with emphasis on prompt response and investigation of alarm activation.
- Placed the Receptionist on administrative leave.
- Initiated an in-service with nursing staff regarding elopement guidelines, including completion of risk assessments, care plan updates, and elopement book updates.
- Initiated additional staff education on elopement guidelines and abuse and neglect.
- Provided education to Social Services regarding elopement guideline oversight.
- Returned (DNS) to educate staff and monitor effectiveness.
- Educated House Supervisors and Managers on Duty regarding elopement book accuracy.
- Ensured no staff member will be permitted to work without completing education.
- Conducted a QAPI meeting to address root cause and corrective action.
Failure to Obtain and Administer Ordered Medications for New Admission
Penalty
Summary
The deficiency involves the facility’s failure to ensure that ordered medications were available and administered as prescribed for one resident on the night of admission. The facility’s Medication Availability form, identified by the Nurse Consultant as the protocol for missing medications, directs staff to check the Emergency Medication Kit (E Kit), call the pharmacy for an estimated delivery time, notify a supervisor, and, if the delay is greater than four hours, call the physician for a plan to address the situation. Record review of the electronic Medication Administration Record (eMAR) for January 2026 showed that on the night of admission, the resident had physician orders for terazosin 1 mg at HS for essential hypertension, dabigatran 150 mg twice daily at HS for paroxysmal atrial fibrillation, and morphine sulfate 30 mg twice daily for pain related to rheumatoid arthritis. All three medications were documented with code 7 (Other/See Progress Notes), indicating they were not administered as ordered. Progress notes dated that night at 11:48 PM contained only the entry "awaiting medications" with no further documentation that the medications were obtained or given in accordance with the facility’s protocol. Interview with an LPN confirmed that, for new admissions, medication orders are transmitted to the pharmacy and that if medications are not available, staff may obtain them from the E Kit or contact the pharmacy, including backup or emergency pharmacy, to secure the medications. The LPN stated that failure to administer the resident’s prescribed medications could result in adverse outcomes. Review of the eMAR and interview with the DON confirmed that the three ordered medications were not administered and that staff did not follow the facility’s protocol for obtaining unavailable medications. Admission records showed the resident was admitted with essential hypertension, paroxysmal atrial fibrillation, and rheumatoid arthritis, requiring ongoing physician-ordered medication management.
Failure to Follow Transfer Protocols Leads to Resident Injury
Penalty
Summary
The facility failed to protect a resident from neglect by not adhering to the prescribed transfer method as outlined in the resident's care plan. The incident involved a Certified Nursing Assistant (CNA) who transferred the resident using a stand-pivot method instead of the required total lift with a medium yellow sling, as specified in the resident's Kardex. This improper transfer method led to the resident being lowered to the floor after expressing discomfort, which was initially assessed by a Registered Nurse (RN) with no apparent injury noted. Within 48 hours of the incident, the resident exhibited swelling and tenderness in the right knee, prompting further medical evaluation. An X-ray revealed a fracture above the previous joint replacement device, leading to the resident's transfer to the emergency room for further treatment. The facility's investigation confirmed that the CNA did not check the Kardex for updated transfer instructions, which contributed to the improper handling of the resident. The resident, who had been admitted to the facility with a diagnosis of dementia and required maximal assistance for transfers, suffered an acute comminuted periprosthetic fracture of the distal femoral metaphysis. The CNA admitted to not checking the Kardex for the resident's current transfer needs, despite being instructed to do so during orientation. This oversight resulted in the resident's injury and subsequent hospitalization.
Failure to Implement Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to implement a resident's care plan when a Certified Nursing Assistant (CNA) transferred a resident using an incorrect method, leading to an injury. The resident, who had a history of dementia and impaired range of motion in the lower extremities, required a total lift with a medium yellow sling and assistance from two staff members for transfers, as outlined in their care plan. However, on the evening of the incident, CNA #1 used a stand-pivot transfer method instead of the required lift, resulting in the resident being eased to the floor after expressing pain. Initially, no injury was noted, but within 48 hours, swelling and a fracture were identified, necessitating further medical evaluation and treatment. Interviews with facility staff revealed that the Kardex, which details the care plan interventions, was not consulted by CNA #1 before the transfer. The facility's policy mandates that CNAs check the Kardex at the beginning of each shift to ensure compliance with care plans. Despite this, CNA #1 admitted to not following the care plan, leading to the resident's injury. The facility's administrator confirmed that the care plan interventions automatically populate the Kardex for CNAs to follow, emphasizing the expectation for staff to adhere to these guidelines.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to accurately submit staffing data into the Payroll-Based Journal (PBJ) system for the first quarter of 2025. The deficiency was identified through staff interviews, record reviews, and analysis of the PBJ staffing data report. The facility's policy on PBJ entry submission was not revised, and it was found that excessively low weekend staffing data was submitted for the specified quarter. Interviews with the Regional Human Resource and Human Resources personnel revealed that the facility's payroll system automatically transferred late clock-ins and shifts crossing midnight to the next shift, which was not manually corrected. This led to discrepancies in the reported staffing data. The Administrator confirmed that the facility had not experienced low staffing and that an on-call person was available on weekends to meet the required patient per day (PPD) staffing levels. However, the payroll system, which had been in use for about a year, had unresolved issues that affected the accuracy of the reported hours. The Administrator acknowledged that the workforce manager's schedule and the human resources report did not align, resulting in incorrect hour capture. This discrepancy in the payroll system contributed to the inaccurate submission of staffing data in the PBJ system.
Failure to Secure Hazardous Chemicals on Housekeeping Carts
Penalty
Summary
The facility failed to ensure the safe storage and locking of hazardous cleaning chemicals on two of the three housekeeping carts observed during the survey. On one occasion, an unattended housekeeping cart on the west hall was found unlocked, containing hazardous chemicals such as Crew Bathroom Disinfectant Cleaner, Virex Plus One-step disinfectant cleaner & deodorant, and Crew clinging Toilet bowl cleaner. Housekeeper #5 confirmed the cart was not locked and mentioned that the locking mechanism was broken, with previous attempts to secure it using tape. She acknowledged the importance of locking the cart to prevent residents from accessing the dangerous chemicals. In another instance, the rehabilitation hall housekeeping cart was locked, but chemicals were stored outside the cart within residents' reach. Housekeeper #4 admitted to storing the chemicals outside because he did not have a key to unlock the cart, having worked at the facility for about a month. The Housekeeping Supervisor was unaware of the issues with the west housekeeping cart and had forgotten to provide Housekeeper #4 with a key. The Administrator was also unaware of these issues, expecting to be notified if there were problems with the cart locks or if additional keys were needed. The Safety Data Sheets for the chemicals indicated potential hazards, including severe skin burns and eye damage, emphasizing the need for secure storage.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection prevention and control practices, as evidenced by several deficiencies observed during the survey. For Resident #4, the Treatment Nurse and a Certified Nursing Assistant did not wear gowns while providing wound care, despite the Enhanced Barrier Precautions (EBP) signage on the door indicating the need for such protective equipment. Both staff members acknowledged their oversight, attributing it to the absence of personal protective equipment at the door. The Infection Control Nurse confirmed that EBP should be followed during wound care to prevent infection spread. Similarly, for Resident #118, a Certified Nursing Assistant did not wear a gown while performing Foley catheter care, despite the EBP sign on the resident's door. The CNA admitted to the oversight and acknowledged the importance of wearing a gown to reduce the risk of bacterial transmission. The Infection Preventionist and Director of Nursing both confirmed that failing to use EBP during catheter care increased the risk of infection spread. For Resident #125, the facility failed to provide biohazard containers for the disposal of contaminated personal protective equipment, despite the resident being on contact precautions for Clostridium Difficile infection. The housekeeping staff used cleaning products that were not effective against C. diff spores, as confirmed by the Housekeeping Supervisor. The Infection Preventionist admitted to not notifying the housekeeping department about the specific precautions needed for Resident #125, which contributed to the improper handling of the resident's clothing and trash, potentially spreading the infection.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that resident call lights were within reach, limiting the ability of two residents to request assistance as needed. For Resident #32, the call light was observed wrapped around the side rail of the bed and out of reach. During an interview, the resident expressed difficulty in using the call light due to its inaccessibility. Staff members, including a CNA and an RN, confirmed the call light's position and acknowledged the oversight, with the CNA admitting to forgetting to reposition it after leaving the room. Resident #32, who is cognitively intact with a BIMS score of 15, has diagnoses including blindness in the right eye and end-stage renal disease. Resident #42's call light was found inside a closed drawer, making it inaccessible while the resident was asleep. Subsequent observations revealed the call light hanging down the side of the nightstand and later on the floor, consistently out of reach. A CNA confirmed the call light's inaccessibility throughout the morning and acknowledged the expectation for it to be within reach. The Director of Nurses emphasized the importance of call light accessibility for resident safety and care. Resident #42 has diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for several residents, as evidenced by multiple maintenance and housekeeping issues that were not addressed in a timely manner. Resident #14's room had a broken headboard with jagged edges, which was reported by the resident but not repaired, posing a potential safety hazard. Similarly, Resident #70's room had mice droppings in the dresser drawers, which were reported but not cleaned, raising health concerns. Resident #79's room had a hole in the wall with a vent cover hanging out, which was not identified or addressed by staff, creating a potential hazard. Resident #17's room had towels on the floor due to a leaking air conditioner, and a window with a gap exposing outside elements, which were not repaired despite being reported. Resident #32's bed remote control had exposed wires, posing a risk of shock, but this issue was not reported to maintenance. Resident #71's mattress was sagging and peeling, and the bed was not functioning, affecting the resident's comfort and positioning, yet these issues were not addressed by maintenance. Resident #87's room had multiple issues, including a broken bed rail, an oxygen concentrator covered in powdery substance, and boxes of supplies on the floor, which were not reported or addressed. Resident #93's overbed light was broken, preventing the resident from turning it off, and this was not repaired despite being reported. Resident #95's room had stained curtains and clutter from boxes on the floor, creating a fall risk, but these issues were not resolved. The facility's failure to address these maintenance and housekeeping issues compromised the safety and comfort of the residents.
Failure to Implement Care Plans for Residents
Penalty
Summary
The facility failed to implement appropriate care plans for several residents, leading to deficiencies in their care. Resident #12, who had a self-care deficit due to a cerebral vascular accident with left hemiplegia, was observed with poor oral hygiene, as a thick white substance was adhered to his gums. Despite the care plan specifying daily oral care, the resident's teeth were neglected, as confirmed by a CNA and the Director of Nurses (DON). This neglect indicates that the care plan was not followed, resulting in inadequate grooming for the resident. Resident #111, who had an ADL self-care performance deficit related to dementia and Parkinson's disease, was found with long, jagged fingernails with a brown substance underneath. Despite the care plan's directive for daily nail care, the resident's nails were not attended to, as confirmed by the DON. Similarly, Resident #118, who required assistance with personal hygiene due to weakness and impaired cognition, was observed with long, unclean fingernails. The DON confirmed that the care plan for personal hygiene was not implemented, leading to the resident not receiving the necessary care. Resident #32, who had end-stage renal disease, was on a 1-liter fluid restriction as per his care plan. However, the facility failed to monitor and document his fluid intake accurately, resulting in the resident exceeding the fluid limit on multiple days. An LPN admitted to not verifying the fluid intake from meal trays, and the DON acknowledged the oversight. The MDS Nurse confirmed that the failure to monitor and document the fluid restriction was a failure to implement the care plan, which was intended to prevent complications associated with impaired renal function.
Failure to Provide Adequate ADL Care
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) care for three residents who were dependent on staff assistance. Resident #12 was observed with a thick white substance on their teeth, indicating a lack of oral hygiene care. Despite having a hospice aide visit twice a week, the responsibility for daily oral care was acknowledged by the staff, including a CNA and an RN, who admitted that the resident's oral care had been neglected. The Director of Nurses confirmed that all residents should receive proper grooming, including oral care. Resident #111, a diabetic, had long, jagged fingernails with a brown substance underneath, and expressed dissatisfaction with their condition. The resident stated that the nurse was responsible for cutting their nails, but it was unclear when this would occur. A CNA confirmed the need to notify nurses about the resident's nail care, which had not been done. Similarly, Resident #118 had long, jagged fingernails with a dark brown substance underneath, and expressed a dislike for their length. An RN confirmed the need for nail care, noting the potential risk of skin breakdown or infection. The DON acknowledged that Resident #118 was dependent on staff for personal care and should have received nail care.
Breach of Privacy Due to Unattended EMARs
Penalty
Summary
The facility failed to secure electronic health records, resulting in a breach of privacy for two residents. On the [NAME] unit, a computer on a medication cart was left unattended with the Electronic Medication Administration Record (EMAR) of Resident #86 visible on the screen. This occurred when LPN #1 stepped away from the cart to assist another resident, leaving the screen open and accessible to anyone passing by. The visible information included the resident's name, medications, and room number. LPN #1 acknowledged the oversight and confirmed that the EMAR should have been closed to protect the resident's private health information. Similarly, on the same day, another incident occurred on the [NAME] Hall where Resident #104's EMAR was left visible on an unattended medication cart. LPN #1 admitted to leaving the cart unattended with the resident's information displayed, acknowledging that this was a violation of privacy. The Director of Nursing confirmed that resident information should not be left visible on unattended computers, recognizing this as a privacy issue. Both residents' admission records were reviewed, confirming their residency at the facility.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that a medication cart was locked and medications were secured during one of the four survey days. According to the facility's policy titled 'Medication Storage,' it is the responsibility of the facility to keep the medication cart locked and secure at all times when not in use. On March 18, 2025, at 11:44 AM, an observation revealed that the medication cart in the [NAME] Wing was left unattended and unlocked by the door of room W-18. A medication cup containing six pills was found sitting on top of the cart, and two visitors walked by the unattended cart. At 11:50 AM, an LPN returned to the cart and confirmed that she had left it unlocked with medications exposed. She admitted that she had stepped away from the cart to assist in moving a bed, acknowledging that she should have secured the medications or completed her task without leaving the cart unattended. The medications in the cup were identified as Lasix, Amiodarone, Protonix, Eliquis, Tamsulosin, and Midodrine. The Director of Nurses confirmed that the facility's expectation and policy require all medication carts to be locked and medications to be kept secure when unattended, aligning with nursing standards of practice.
Failure to Document and Obtain Orders for PICC Line Care
Penalty
Summary
The facility failed to ensure accurate documentation and proper physician orders for the care of a resident with a Peripherally Inserted Central Catheter (PICC). During an observation, a Registered Nurse (RN) flushed the resident's PICC line and started an antibiotic infusion without a physician's order to do so. The resident's Electronic Medication Administration Record (EMAR) did not contain an order for flushing the PICC or changing the dressing, which was confirmed by another RN and the Director of Nursing. The resident was admitted with a medical diagnosis that included aftercare following the explantation of a knee joint prosthesis.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of mice droppings in a resident's dresser drawers. The issue was first noticed by the resident's husband and subsequently reported to the staff. Upon inspection, a Certified Nurse Assistant confirmed the presence of numerous black substances resembling mice droppings in multiple drawers. This finding was corroborated by a Registered Nurse, who expressed concern about potential contamination of the resident's clothing with feces and bacteria. The facility's policy on pest control, effective since September 1, 2014, was not effectively implemented in this instance. The Maintenance Supervisor acknowledged receiving a work order regarding the issue, which was reported on March 15, 2025. The resident involved was cognitively intact, as indicated by a Brief Interview for Mental Status score of 15, and had been admitted with a diagnosis of Occlusion and Stenosis of an Unspecified Vertebral Artery. The presence of mice droppings in the resident's personal space posed a potential health hazard, as confirmed by the facility's Administrator.
Failure to Monitor Fluid Intake for Dialysis Resident
Penalty
Summary
The facility failed to accurately monitor and document fluid intake for a resident receiving dialysis, leading to a deficiency. The resident, diagnosed with End-Stage Renal Disease, had a physician's order for a one-liter fluid restriction per day. However, a review of the resident's Electronic Medication Administration Record (eMAR) revealed that the resident exceeded this fluid intake on multiple days. The Licensed Practical Nurse (LPN) responsible for documenting the fluid intake admitted to only recording the fluids she administered during her shift and was unaware of the total daily intake, leading to uncertainty about adherence to the fluid restriction. Further interviews with the Director of Nursing (DON) and a Nurse Practitioner (NP) confirmed the inconsistency and inaccuracy in the documentation of the resident's fluid intake. Both acknowledged the difficulty in determining whether the resident adhered to the fluid restriction due to unclear documentation. The DON was uncertain if the fluid provided with meals was included in the recorded intake, and the NP agreed that the failure to accurately monitor fluid intake could worsen the resident's medical condition.
Failure to Change Wound Vac Dressing as Ordered
Penalty
Summary
The facility failed to ensure a resident received treatment and services in accordance with professional standards of practice by not changing the negative pressure wound therapy (NPWT) system dressing as ordered. The resident had an order for the wound vac dressing to be changed every Monday and Thursday or as needed for drainage/dislodgement. However, the dressing was not changed from 4/1/2024 to 4/10/2024, resulting in the foam from the dressing adhering to the wound bed. This was confirmed by the resident's representative, the wound care nurse practitioner, and the facility's registered nurse, who all noted the lack of documentation and the physical state of the wound upon assessment. The resident's wound vac dressing was last changed on 3/25/2024, and it was not changed again until 4/10/2024, despite the order. The wound care nurse practitioner had to debride the wound to remove the adhered foam fragments, but not all fragments could be removed. The facility's administrator acknowledged that the dressing should have been changed as ordered. The failure to follow the prescribed treatment schedule led to complications in the resident's wound care, as evidenced by the adhered foam and the need for debridement.
Failure to Implement Elopement Risk Plan
Penalty
Summary
The facility failed to implement an elopement/wandering risk plan of care for a resident who had a documented history of wandering and elopement attempts prior to his admission. Despite being identified as a wanderer and wearing a wander guard since admission, the resident was able to exit the facility unsupervised and undetected by staff. The resident was missing for approximately ten to twenty minutes before being found off the facility grounds by the police and returned by a staff member. The facility's failure to provide adequate supervision and ensure the proper functioning of the wander guard system led to this incident. The resident's care plan, initiated upon admission, included interventions such as checking the placement and function of the wander guard every shift and redirecting the resident from doors. However, the Medication Administration Record (MAR) revealed multiple instances where the wander guard was not checked as required. Interviews with facility staff confirmed that the kitchen door was not properly shut, allowing the resident to leave undetected. The Assistant Director of Nursing (ADON) and the MDS/Care Plan nurse acknowledged the deficiencies in the care plan and the failure to monitor the wander guard effectively. The resident was admitted with diagnoses including senile degeneration of the brain, dementia, muscle weakness, unsteadiness on feet, abnormalities of gait or mobility, lack of coordination, and cognitive communication deficit. Despite these conditions, the facility did not adequately address the resident's elopement risk, leading to the incident. The facility's policies on care plans and elopement risk were not followed, resulting in a serious lapse in resident safety and supervision.
Removal Plan
- Resident #1 was assisted back to the facility via facility staff personal vehicle and thoroughly assessed by RN #1 with no adverse injuries/incidents found.
- RN #1 contacted the RR, the Medical Director, the facility Administrator, the facility ADON, and placed Resident #1 on one to one close observation by facility staff.
- The elopement risk assessment was updated for Resident #1 and the care plan was revised.
- The elopement book kept at the nursing station was reviewed and updated.
- Facility staff conducted room to room audits of all residents in the building to ensure safety.
- The facility conducted a Quality Assurance meeting with the Medical Director in attendance via telephone.
- Elopement drills were conducted on all three shifts.
- All residents with wander guard bracelets were checked for functionality and positioning on each shift.
- The ADM and the ADON began in-services of all staff on elopement protocol, wander guard monitoring, and Abuse and Neglect.
- All doors and windows were checked for proper functioning and operation.
- ADM began an investigation to determine how Resident #1 eloped.
- ADM called the incident in to the Mississippi State Department of Health office.
- Resident #1 was placed on one to one close observation immediately upon his return to the facility and remained on one to one by staff until his transfer.
- A staff member was placed at the front door to monitor the entrance and exits of the building 24/7 until the new wander guard alarm system was installed.
- No staff were allowed to work until they were in-serviced on elopements, Abuse/Neglect, and monitoring of wander guard systems.
- RN#1 notified the ADM, the ADON, the Maintenance Director, the RR, and the MD via telephone of the elopement of Resident #1.
- A 100% head count of all residents was conducted to ensure they were all accounted for.
- All doors were monitored by staff 24/7 until the wander guard system was found fully functioning and new punch pad systems were installed on the kitchen doors.
- Four residents with risks of elopement were reevaluated and updated to ensure all residents at risk for elopement had appropriate interventions in place.
- RN #1 and the ADM began officially investigating and obtaining statements for the Elopement of Resident #1.
- Staff in-services were initiated by RN #1, the ADON, and the ADM to include all staff on Elopement Protocols, Wander Guard checks, and Abuse/Neglect.
- A QA meeting was held via telephone with the MD, the ADON, ADM, MDS/Care Plan Nurses, Maintenance Director, Dietary Manager, Social Worker, and the QA/Infection Control Nurse.
- The Maintenance Director checked the functioning of the wander guard alarm/security system and found that the alarm was functioning properly.
- New punch pads and alarms and locks were installed on the kitchen doors.
- The ADM contacted the SA and the MS Attorney General's Office to report the elopement of Resident #1.
Resident Elopement Due to Inadequate Supervision and Door Malfunction
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident, identified as an elopement and wandering risk, from exiting the facility unnoticed and unsupervised. The resident was missing for approximately ten to twenty minutes before being discovered at an apartment complex parking lot, talking to the police. The resident was returned to the facility by a staff member and was found to be uninjured and in no distress. The incident occurred because the kitchen door was not properly closed and locked, allowing the resident to leave undetected as the wander guard alarm did not sound. The resident had been identified upon admission as a wanderer and had a wander guard alarm placed on his ankle. However, the kitchen area did not have a wander guard alarm system, and no staff were assigned to that area late at night. The facility's policy on missing residents and elopement was not effectively implemented, as the door's malfunction allowed the resident to exit the facility without triggering the alarm or alerting the staff. Interviews with various staff members, including the Administrator, Assistant Director of Nursing, Certified Nursing Assistants, and the Maintenance Director, confirmed that the kitchen door was not properly shut, which allowed the resident to leave the facility undetected. The resident's care plan and elopement risk assessment had identified him as a wanderer, but the failure to secure the kitchen door and the lack of staff monitoring in that area led to the resident's unsupervised exit from the facility.
Removal Plan
- Resident #1 was assisted back to the facility via facility staff personal vehicle and thoroughly assessed head to toe by RN #1 with no adverse injuries/incidents found.
- RN #1 contacted the Resident Representative, the Medical Director, the facility Administrator, the facility ADON, and placed Resident #1 on one to one close observation by facility staff.
- The elopement risk assessment was updated for Resident #1 and the care plan was revised.
- The elopement book kept at the nursing station was reviewed and updated.
- Facility staff conducted room to room audits of all residents in the building to ensure safety.
- The facility conducted a Quality Assurance meeting with the Medical Director in attendance via telephone.
- Elopement drills were conducted on all three shifts.
- All residents with wander guard bracelets were checked for functionality and positioning on each shift.
- The ADM and the ADON began in-services of all staff on elopement protocol, wander guard monitoring, and Abuse and Neglect.
- All doors and windows were checked for proper functioning and operation.
- ADM began an investigation to determine how Resident #1 eloped.
- ADM called the incident in to the Mississippi State Department of Health office.
- Resident #1 was placed on one to one close observation immediately upon his return to the facility and remained on one to one by staff until his transfer.
- A staff member was placed at the front door to monitor the entrance and exits of the building 24/7 until the new wander guard alarm system was installed.
- No staff were allowed to work until they were in-serviced on elopements, Abuse/Neglect, and monitoring of wander guard systems.
- RN#1 notified the ADM, the ADON, the Maintenance Director, the RR, and the MD via telephone of the elopement of Resident #1.
- The facility staff conducted a 100% head count of all residents to ensure they were all accounted for.
- All doors were monitored by staff 24/7 until the wander guard system was found fully functioning and new punch pad systems were installed on the kitchen doors.
- Four residents with risks of elopement were reevaluated and updated to ensure all residents at risk for elopement had appropriate interventions in place.
- RN #1 and the ADM began officially investigating and obtaining statements for the Elopement of Resident #1.
- Staff in-services were initiated by RN #1, the ADON, and the ADM to include all staff on Elopement Protocols, Wander Guard checks, and Abuse/Neglect with no staff allowed to work until in-services were completed.
- A QA meeting was held via telephone with the MD, the ADON, ADM, MDS/Care Plan Nurses, Maintenance Director, Dietary Manager, Social Worker, and the QA/Infection Control Nurse.
- The Maintenance Director checked the functioning of the wander guard alarm/security system and found that the alarm was functioning properly and the alarm was sounding.
- The vendor installed new punch pads and alarms and locks to the kitchen doors.
- The ADM contacted the SA and the MS Attorney General's Office to report the elopement of Resident #1.
Facility Fails to Provide Safe, Clean, and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment as evidenced by multiple deficiencies observed by surveyors. The East Wing hall had damaged floors with buckled, unsecured vinyl flooring, indentations, and peeling laminate, posing a hazard to residents, staff, and visitors. Additionally, the floors in the [NAME] wing hall were dirty with discarded paper, dried liquid stains, and food crumbs. The facility also failed to provide clean linens, as observed in the case of Resident #2, who was found lying in bed without sheets or a full blanket in cold weather conditions. The linen closets on the [NAME] Wing and East Wing were found to be empty, and the laundry room was backed up with dirty laundry due to only one working washer. The Administrator and staff confirmed the lack of clean linens and the ongoing issues with the laundry equipment. The facility's shower room on the [NAME] Wing had been broken for about two months, resulting in residents receiving bed baths instead of showers. Housekeeping and maintenance issues were also prevalent, with observations of unclean resident rooms, including dried brown substances and food crumbs on the floors. Housekeeping staff failed to adequately clean these areas, and there were reports of foul-smelling garbage piling up in the biohazard room on the East Wing. The Environmental Manager and housekeeping staff acknowledged the deficiencies and the need for better cleanliness and garbage disposal practices. Interviews with staff and residents revealed ongoing concerns about the cleanliness and safety of the facility. Maintenance staff confirmed multiple water leaks and inadequate repairs to the East Wing floors, which remained unlevel and hazardous. The Administrator and Director of Nursing acknowledged the deficiencies and the need for improvements in laundry, housekeeping, and maintenance practices. The facility's failure to address these issues in a timely manner resulted in an unsafe and uncomfortable environment for the residents.
Failure to Provide Adequate Bedding and Protection from Cold
Penalty
Summary
The facility failed to provide a resident with adequate bedding and protection from cold temperatures. An observation revealed that the resident was lying on a bare mattress with no sheets or bedspread, covered only by a small velour throw, while the window in the room was open, and the outside temperature was 38 degrees. Interviews with the LPN and CNA confirmed the lack of clean linens and blankets in the building and the unnecessary opening of the window. The Administrator and the Director of Nurses acknowledged that the resident should have had proper bedding and that the window should not have been open in such cold weather. The resident involved was admitted to the facility with a medical diagnosis of Hypokalemia and had a BIMS score indicating moderate cognitive impairment. The deficiency was identified through staff interviews, record reviews, and direct observations, highlighting a failure to honor the resident's right to a dignified existence and proper care. The lack of clean linens and the open window in cold weather were significant factors contributing to the deficiency.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to implement a comprehensive care plan for three residents requiring assistance with Activities of Daily Living (ADLs). Resident #6 was observed to be disheveled, with oily hair and unshaven facial hair, and reported not having had a shower in about two weeks. The Treatment Nurse and the Minimum Data Set (MDS) Nurse confirmed that the resident's care plan, which required extensive assistance with bathing and personal hygiene, was not being followed. The Director of Nursing (DON) also confirmed that the staff was not adhering to the care plan, resulting in the resident not receiving the necessary care. Resident #1, who requires extensive assistance with toileting due to weakness and debility, reported having to wait for a female Certified Nursing Aide (CNA) to provide care, sometimes waiting up to eight hours while wet. The resident had complained to both the head nurse and the administrator about not wanting a male CNA, but the issue persisted. The resident's care plan indicated the need for assistance with ADLs, but the facility failed to provide timely and appropriate care. Resident #3, who has an ADL self-care deficit related to chronic debilitation and weakness, reported mainly receiving bed baths and not being taken to the bathroom during the day. The resident preferred showers but could not remember the last time he had one. The DON confirmed that residents were mainly given bed baths because some aides found it easier, and acknowledged that not all nursing staff were meeting basic care expectations. The resident's care plan required extensive assistance with toileting, but the facility did not follow through with the necessary care.
Inadequate Staffing Leads to Poor Resident Care
Penalty
Summary
The facility failed to provide sufficient staff to meet the needs of residents, resulting in inadequate assistance with bathing, grooming, and personal hygiene for three residents. Certified Nurse Aides (CNAs) reported that the night shift staffing was reduced from four to three aides per wing, making it difficult to provide timely care. One resident had to wait up to eight hours for a female CNA to provide incontinent care due to her preference for female staff, which was not accommodated promptly. Another resident had not been shaved or given a shower for about two weeks, and a third resident reported receiving mainly bed baths and not being taken to the bathroom during the day as needed. Interviews with staff confirmed the staffing issues, with one Licensed Practical Nurse (LPN) stating that the workload was overwhelming and that residents did not receive showers as they should. The Director of Nurses (DON) acknowledged that some staff were not meeting basic care expectations and that bed baths were more common due to aides finding them easier. The Workforce Manager admitted to insufficient training in scheduling, leading to low staffing levels on certain days and a lack of adjustments for call-ins or one-on-one care requirements. The Administrator was unaware of the Workforce Manager's lack of training and the resulting staffing concerns. The facility's policy on Activities of Daily Living (ADLs) was not followed, as residents did not receive care in accordance with accepted standards, their care plans, or their preferences. The deficiency was evident through observations, interviews, and record reviews, highlighting the facility's failure to provide adequate staffing and care for its residents.
Non-Functioning Call Lights in Resident Rooms
Penalty
Summary
The facility failed to ensure that call lights were functioning in all resident rooms, as evidenced by the non-functioning call lights in the rooms of two residents. An observation revealed that the call light in one resident's room was on but did not make any noise to alert staff. The resident confirmed that there were no call light cords in the room and that he had never had a bell to use. The LPN confirmed the issue and stated that a work order needed to be put in. Another observation showed that the call light cords were present but did not make any noise when activated. The LPN was unaware of the issue and stated that maintenance needed to be notified. The maintenance staff confirmed that they had not been made aware of the broken call light. Another resident confirmed that the staff responded when he called for them, but when he pressed his call light, it did not work. The treatment nurse present in the room confirmed the malfunction. The Administrator and DON confirmed that the call light would come on but not make any noise at the nurse's station, and a work order should have been submitted. The DON acknowledged that non-functioning call lights could lead to problems for residents if they are unable to call for help. Both residents involved were cognitively intact, as indicated by their BIMS scores of 13 on their respective MDS assessments.
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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