Diversicare Of Tupelo
Inspection history, citations, penalties and survey trends for this long-term care facility in Tupelo, Mississippi.
- Location
- 2273 South Eason Boulevard, Tupelo, Mississippi 38804
- CMS Provider Number
- 255105
- Inspections on file
- 32
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Diversicare Of Tupelo during CMS and state inspections, most recent first.
A cognitively intact male resident inappropriately touched the breast of a moderately cognitively impaired female resident while both were seated together in the dining room without staff present. A dietary staff member observed the male resident stroking the female resident’s face and hair, and a CNA then witnessed the breast touching and reported it. The male resident later admitted to the touching and stated he did it because he loved her or to see her reaction, while the female resident, who had dementia and a BIMS score indicating moderate cognitive impairment, was unable to recall the incident. These events occurred despite the facility’s abuse policy stating it would take steps to prevent abuse and neglect.
A resident with hemiplegia and hemiparesis, requiring extensive two-person assistance for bed mobility and toileting, was injured after a CNA provided care alone, contrary to the Kardex instructions. The resident fell from the bed while being turned, resulting in a skin tear, facial swelling, bruising, and a maxillary hematoma, necessitating increased pain management with tramadol.
Two residents admitted from the hospital did not receive their prescribed medications on time due to delays in obtaining them from the facility's pharmacy, which was not local and did not have the required drugs in the on-site dispensing system. Staff interviews revealed that medication orders entered late in the day sometimes resulted in delayed start times, and both the DON and administrator acknowledged that the facility failed to provide timely pharmaceutical services, resulting in missed doses for antibiotics and other critical medications.
The facility failed to honor the voting rights of residents during the 2024 presidential election. Several residents expressed their desire to vote but were not provided with the necessary assistance. A resident who was unable to walk requested a mail-in ballot but did not receive one, while another was promised a ballot by staff but did not receive it. The facility's Social Services staff member acknowledged the oversight, resulting in several residents being unable to exercise their right to vote.
The facility was found deficient in several areas, including administration, resident care, medication management, and infection control. Residents reported ongoing dissatisfaction with food quality, and issues were noted with incontinent care and unauthorized medications. Unattended medication carts and inadequate implementation of Enhanced Barrier Precautions further highlighted the facility's failure to use resources effectively.
The facility's QAA committee failed to maintain and monitor interventions after a recertification survey, leading to repeated deficiencies in areas such as ADL care. Despite implementing EMBRACE rounds to identify issues, the facility struggled with follow-up and addressing root causes, resulting in a pattern of ineffective quality assurance efforts.
Two residents in a LTC facility were observed with uncovered urinary catheter bags, violating their dignity. One resident expressed embarrassment about being transported to therapy with the uncovered bag. Staff, including the ADON, RN Unit Manager, and DON, acknowledged the issue, confirming that catheter bags should be covered as per facility policy.
The facility failed to inform all residents about Resident Council meetings, limiting their participation and ability to voice grievances. Residents expressed dissatisfaction with food quality, citing issues like undercooked meals. Despite repeated complaints, grievances were not resolved, and the facility lacked a structured process to address these issues.
Two residents experienced deficiencies in their care environment. A resident had a frayed electric bed control cord with exposed wires, posing a safety hazard that had been unaddressed for over a year. Another resident's wheelchair was found dirty, with staff acknowledging the night shift's responsibility for cleaning it. Both residents were cognitively intact and had specific medical conditions requiring assistance.
The facility failed to implement comprehensive care plans for three residents, leading to deficiencies in their care. A resident with a history of nicotine dependence was found with smoking materials in his room, contrary to his care plan. Two residents with self-care deficits were observed with long, untrimmed fingernails, despite their care plans specifying regular nail care. Interviews confirmed that the care plans were not followed, resulting in inadequate care for these residents.
A facility failed to provide necessary ADL care for three residents, including nail and incontinent care. A resident was found with saturated briefs and a strong urine odor, indicating missed rounds. Two residents had long, jagged fingernails, risking infection. Staff confirmed these deficiencies, acknowledging the failure to adhere to care protocols.
The facility failed to prevent accident hazards by allowing a resident to have smoking materials in their room and another resident to self-administer medications without an order. The presence of a cigarette box in a resident's room violated the facility's smoking policy, while another resident had medications on their bedside dresser, posing a risk of double dosing. The facility relied on an honor system to manage smoking materials and was unaware of the self-administration of medications.
The facility failed to securely store medications, as observed with two medication carts. An LPN left a cart unattended with a medicine cup and bottles of magnesium, Colace, and calcium on top. The ADON confirmed this was against policy. In another instance, an RN left medication cards unsecured on a cart. Both staff members acknowledged the potential hazard of leaving medications accessible to residents.
The facility failed to implement Enhanced Barrier Precautions (EBP) and infection control measures, affecting 11 residents. Observations showed inadequate EBP signage and staff unfamiliarity with EBP, despite prior in-service training. A CNA placed a soiled bed pad on the floor, and an LPN did not wear a gown while administering PEG tube medication, both actions posing infection risks. The number of residents on EBP increased during the survey, indicating initial under-implementation.
A resident, admitted with COPD and cognitively intact, repeatedly did not receive her preferred sweet tea with meals, despite it being listed on her meal ticket. The Dietary Manager confirmed the oversight, acknowledging the resident's right to have her preferences honored, as per facility policy.
The facility failed to ensure advance directives were properly addressed for three residents. One resident was unaware of their DNR status and wished to be a full code, another had a mismatch between their written directive and electronic records, and a third had an incomplete directive form. These issues were due to oversight and errors in handling advance directives.
A facility failed to protect resident information when a medication cart was left unattended with a visible list of resident names, room numbers, code status, and hospice or dialysis status. The ADON and DON confirmed this as a privacy violation, and the LPN responsible acknowledged the oversight. The list included details of 26 residents.
The facility failed to conduct a timely background check for a newly hired RN Unit Manager, as required by their policy. The background check was outdated, having been completed over two years before the hire date. Interviews with the Administrator, ADON, and Human Resources confirmed the oversight, acknowledging the need for an updated check to ensure no disqualifying events.
A facility failed to update a resident's care plan to include a raised perimeter air mattress used for fall prevention. Despite observations and staff interviews confirming the mattress's purpose, the care plan was not revised to reflect this intervention. The resident, diagnosed with Huntington's Disease, was admitted with specific needs that required the care plan to be updated according to facility policy.
A facility failed to administer IV antibiotics as ordered for a resident with a UTI. The MAR showed missing documentation for three days of a five-day course of Meropenem, confirmed by interviews with nursing staff. The resident, cognitively intact and dependent on renal dialysis, did not receive the full course of treatment, as confirmed by the DON.
The facility failed to assess and obtain consent for bed rails for two residents, leading to deficiencies in care. One resident with Huntington's Disease was observed with unauthorized bed rails, and the DON was unaware of their presence. Another resident with multiple health issues was found with improperly positioned bed rails, contrary to their assessment. Both cases lacked necessary consent, indicating a lapse in the facility's processes.
The facility failed to provide meals that met residents' preferences and were served in an appealing manner, affecting four residents. Complaints included repetitive, unappetizing meals, overcooked or frozen food, and lack of alternative options. Despite being aware of these issues, the Dietary Manager and Registered Dietician did not intervene, and food committee meetings ceased during the Dietary Manager's maternity leave, leaving complaints unresolved.
A resident with reduced mobility and no cognitive deficits was denied assistance with toileting by a CNA, who suggested using a brief instead. This refusal was observed by a state agency representative. Interviews with facility staff confirmed the CNA's actions were inappropriate and against the facility's policy on resident dignity.
Two residents experienced deficiencies in personal hygiene care due to the facility's failure to implement ADL care plans. One resident, with a self-care deficit, was not shaved as per her care plan, despite her request. Another resident had not received oral care since admission and lacked necessary supplies, resulting in poor oral hygiene. The DON confirmed that care plans were not followed, leading to these deficiencies.
Two residents in the facility did not receive adequate personal care, specifically in shaving and oral hygiene. One resident, with no cognitive deficits, was not shaved as per her preference, despite it being part of her care plan. Another resident, with moderate cognitive deficits, had not been provided with a toothbrush or toothpaste since admission and was not shaved regularly. The facility's policy requires care to be provided according to standards and resident preferences, but these were not met for the residents involved.
Failure to Prevent Sexual Abuse Between Residents in Dining Area
Penalty
Summary
The facility failed to protect a resident from sexual abuse when one cognitively intact male resident inappropriately touched the breast of a moderately cognitively impaired female resident. The incident occurred while both residents were seated together at a dining table without staff present in the dining room. A dietary staff member first observed the male resident stroking the female resident’s face and rubbing her hair, and then a CNA entered and directly observed him touching the female resident’s breast over her shirt. When confronted, the male resident stated he did not care if the incident was reported. Subsequent interviews and documentation showed that the male resident admitted to touching the female resident’s breast, variously explaining that he did it because he loved her, that it was what men do when they are in love, and that he wanted to see her reaction. The female resident had been admitted with unspecified dementia with mood disturbance and had a BIMS score of 11, indicating moderate cognitive impairment. During surveyor interviews, she was ambulatory but displayed a flat affect, responded only to simple questions, and was unable to consistently understand or recall the incident, stating she did not remember what had occurred. The male resident, admitted with epilepsy, anxiety disorder, and unspecified mood disorder, had a BIMS score of 15, indicating he was cognitively intact. He acknowledged being attracted to the female resident and having talked with her for a day or two before the incident, and also acknowledged being attracted to other female residents in the past, though he denied touching them. These events and conditions occurred despite the facility’s written abuse policy stating it would take appropriate steps to prevent abuse, neglect, injuries of unknown origin, and misappropriation of resident property.
Failure to Provide Required Two-Person Assistance Results in Resident Fall and Injury
Penalty
Summary
Staff failed to follow the resident's Kardex instructions requiring two-person assistance for bed mobility and toileting, resulting in a fall. On the day of the incident, a CNA was providing incontinent care to a resident with hemiplegia and hemiparesis following a cerebral infarction, who was documented as needing extensive two-person assistance for both bed mobility and toileting. The CNA attempted to turn the resident alone, during which the resident reached for the over-bed table and fell from the bed. This incident was confirmed by interviews with the CNA, other staff, the DON, and the Administrator, as well as a review of the Kardex and MDS documentation, all of which indicated the requirement for two-person assistance. As a result of the fall, the resident sustained a skin tear to the buttocks, facial swelling, bruising, and a maxillary hematoma, which led to increased pain and a new order for tramadol, an opioid analgesic. Prior to the fall, the resident had only required minimal pain management. The facility's policy required a safe environment and adherence to care plans, but staff did not follow the documented care instructions, directly resulting in the resident's injuries.
Failure to Provide Timely Pharmacy Services for Newly Admitted Residents
Penalty
Summary
The facility failed to provide timely pharmacy services to meet the medication needs of two residents following their admission from the hospital. Both residents were admitted with specific medication orders for serious conditions, including a foot infection with osteomyelitis and COPD for one resident, and seizures with pneumonia for the other. Upon review, it was found that the required medications, such as Vancomycin and Augmentin, were not administered as ordered due to delays in obtaining them from the pharmacy. The facility's medication dispensing system did not have these medications available, and the pharmacy used by the facility was not local, resulting in further delays. Interviews with staff, including an LPN and the DON, revealed that the process for entering medication orders into the facility's system sometimes resulted in start times being set for the following day if entered after a certain hour. This contributed to the missed doses, as the medications were not available in the facility and were not delivered in time for administration. The DON acknowledged that it was the nurses' responsibility to obtain information about the last dose given at the hospital and to ensure medications were administered as ordered, but this did not occur for the two residents in question. The administrator confirmed that the facility admitted residents without ensuring the immediate availability of their required medications and that pharmacy services were not able to provide the ordered medications in a timely manner. Both residents missed critical doses of their prescribed medications, and this failure was acknowledged by facility leadership as a deficiency in providing necessary pharmaceutical services.
Failure to Honor Residents' Voting Rights
Penalty
Summary
The facility failed to honor the voting rights of residents during the 2024 presidential election. Three residents, identified as #4, #5, and #6, expressed their desire to vote but were not provided with the necessary assistance to do so. Resident #6, who was unable to walk, requested a mail-in ballot but did not receive one. Resident #7 was promised a ballot by the staff but did not receive it, and Resident #8, who was registered to vote, was not taken to the polling station. The facility's Social Services staff member acknowledged the oversight, stating that she mistakenly believed that registration would automatically result in absentee ballots being mailed to the residents. This misunderstanding, coupled with a lack of timely action, resulted in several residents being unable to exercise their right to vote. The facility's policy on Resident's Rights and Quality of Life emphasizes the right of residents to a dignified existence and the ability to exercise their rights as citizens. However, the facility did not ensure that these rights were upheld, as evidenced by the failure to assist residents in voting. The administrator confirmed the facility's failure to properly assist residents in exercising their voting rights. The record review showed that out of 47 residents who desired to vote, only a small number were able to do so, with several residents not receiving the necessary support to vote either by absentee ballot or in person.
Deficiencies in Administration and Care Practices
Penalty
Summary
The facility was found to be deficient in several areas during a survey, indicating a failure to administer the facility in a manner that effectively uses its resources to ensure resident well-being. One significant issue was the lack of an Administration Policy, as confirmed by the Administrator. This deficiency was cross-referenced with multiple tags, including F 565, F 677, F 689, F 761, and F 880, highlighting various areas of concern. For instance, residents expressed dissatisfaction with the food quality during resident council meetings, and it was noted that these complaints were not consistently documented or addressed, as confirmed by the Administrator. In another instance, Resident #7 was found in a room with a strong odor of urine, indicating a lack of timely incontinent care. The resident was wearing two heavily saturated briefs, which was not in accordance with care protocols. The CNA responsible admitted to not making rounds as required, and the DON acknowledged that such neglect could increase the risk of skin breakdown. Additionally, Resident #22 was found with smoking materials in his room, contrary to facility policy, and Resident #34 had unauthorized medications, raising concerns about potential overmedication. Further deficiencies were observed in medication management and infection control practices. Unattended medication carts were found with unsecured medications, posing a risk to residents. The facility also failed to implement Enhanced Barrier Precautions (EBP) effectively, as staff were either unaware or inadequately trained on the procedures. This was evident when a nurse administered medication without donning appropriate protective gear, despite EBP signage. The Administrator admitted to a lack of follow-up on staff training and implementation of EBP, which could lead to infection control issues.
Ineffective QAA Program Leads to Repeated Deficiencies
Penalty
Summary
The facility's Quality Assurance and Assessment (QAA) committee failed to maintain and monitor the interventions they implemented following a recertification survey conducted on June 22, 2023. This failure was evident during a subsequent recertification survey on September 16, 2024, where the facility was cited for multiple deficiencies, including F 550, F 565, F 584, F 656, F 677, F 689, F 761, and F 880. The repeated deficiencies across two state surveys indicate a pattern of ineffective QAA program implementation. The facility's policy on Quality Assurance and Performance Improvement (QAPI) emphasizes a proactive approach to improving quality of life and care, involving team members at all levels to identify improvement opportunities and monitor the effectiveness of interventions. However, the facility's inability to sustain these efforts was highlighted by the recurrence of deficiencies. Interviews with the Administrator (ADM) revealed that the facility's EMBRACE rounds, intended to identify and correct issues, were not effectively addressing the root causes of deficiencies. The ADM acknowledged that while staff identified deficient practices during rounds, the follow-up was lacking. The ADM also noted that the facility's focus on daily operations and staffing led to oversight of critical details, resulting in a disconnect in monitoring and follow-up. The ADM admitted that both the floor staff and leadership, including herself and the Director of Nurses (DON), failed to consistently identify and address issues, leading to complacency when monitoring ceased.
Failure to Maintain Resident Dignity with Uncovered Catheter Bags
Penalty
Summary
The facility failed to uphold the dignity of residents by not covering urinary catheter bags, as observed in two residents. Resident #52 was seen with an uncovered urinary catheter bag containing approximately 100 cc of urine during multiple observations. The Assistant Director of Nurses confirmed that the lack of a privacy cover was a dignity issue, as per the facility's policy. Resident #52 had been admitted with diagnoses including seizures, urinary tract infection, and cognitive communication deficit, and the Minimum Data Set indicated the presence of an indwelling catheter. Similarly, Resident #190 was observed with an uncovered catheter bag containing 350 ml of urine, facing the door. The resident expressed concern about being wheeled to physical therapy with the uncovered bag, feeling embarrassed. The RN Unit Manager and the Director of Nursing acknowledged the dignity issue, agreeing that catheter bags should be covered. Resident #190, who was cognitively intact, had diagnoses including obstructive and reflux uropathy, rhabdomyolysis, and paraplegia. The Physical Therapy Assistant admitted to not paying attention to the catheter bag during transport and agreed it should be covered.
Failure to Inform Residents of Council Meetings and Address Grievances
Penalty
Summary
The facility failed to ensure that all residents were informed about the monthly Resident Council meetings, which impeded their ability to participate and voice grievances. Interviews with residents revealed that some were unaware of the meetings, with one resident stating they had never heard of them, and another attending only one meeting in three years. The Activities Director admitted that the meetings were not consistently included on the activities calendar and were sometimes only advertised via flyers in the hallway, which residents might not see. Additionally, the facility did not adequately address grievances raised during the Resident Council meetings, particularly concerning food quality. Multiple residents expressed dissatisfaction with the meals, describing issues such as undercooked or hard-to-chew food. Despite these complaints being raised repeatedly in meetings, there was no evidence of resolutions being implemented. The Social Services staff and the Administrator acknowledged that food complaints were ongoing and unresolved, with the dietary department not consistently documenting or addressing these grievances. The report highlights specific instances where residents voiced their dissatisfaction with the food, including complaints about the menu and the quality of meals served. The Dietary Manager confirmed that complaints were often related to personal preferences, but the issues persisted even after attempts to address them. The lack of a structured grievance process and the absence of a food committee during the Dietary Manager's maternity leave contributed to the ongoing dissatisfaction among residents.
Facility Fails to Maintain Clean and Safe Environment for Residents
Penalty
Summary
The facility failed to maintain a clean and safe environment for its residents, as evidenced by two specific incidents involving residents. Resident #12 had an electric bed control with a frayed cord and exposed wires, which posed a potential safety hazard. Despite the resident's concerns about the risk of burns or fire, the issue had persisted for over a year. Staff interviews confirmed the hazard, and a maintenance supervisor acknowledged the potential for a minor electrical shock if the wires touched. Resident #12 was cognitively intact, with a BIMS score of 15, and had been admitted with diagnoses including Type 2 Diabetes Mellitus and Chronic Kidney Disease. Resident #71's wheelchair was observed to be dirty, with a thick, grayish-dried substance and food crumbs on the base and wheel spokes. The resident expressed dissatisfaction with the cleanliness of the wheelchair. Staff interviews revealed that the night shift was responsible for cleaning wheelchairs, but the task had not been completed for Resident #71. The Assistant Director of Nurses confirmed the wheelchair's unclean state. Resident #71 was also cognitively intact, with a BIMS score of 14, and had been admitted with diagnoses including Cerebral infarction.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to implement comprehensive care plans for three residents, leading to deficiencies in their care. Resident #22, who had a personal history of nicotine dependence, was found with a cigarette box containing a cigarette and a used cigarette butt in his room, despite his care plan stating that he should not have smoking materials on his person. This indicates that the care plan was not followed, as confirmed by the Assistant Director of Nursing. Resident #58, who had an ADL self-care performance deficit due to contractures and decreased mobility, was observed with long, jagged fingernails, despite his care plan specifying that nail care should be performed on bath days and as needed. Interviews with the resident, a CNA, and the Administrator confirmed that the care plan for nail care was not followed, as the resident's nails were not checked and trimmed as required. Similarly, Resident #59, who had a self-care deficit related to a history of CVA and decreased functional abilities, was found with long, jagged fingernails and a brown substance under some nails. His care plan included daily nail care, but interviews with the resident and the Administrator revealed that this aspect of the care plan was not adhered to, as the resident had not received the necessary assistance to maintain his nail hygiene.
Deficiencies in ADL Care for Residents
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADL) care for three residents, specifically in the areas of nail care and incontinent care. Resident #7 was observed to be lying in bed with a strong odor of urine in the room, indicating a lack of timely incontinent care. Certified Nurse Aide (CNA) #7 confirmed that the resident was incontinent and had not been checked since the start of her shift, revealing that the resident was wearing two heavily saturated incontinent briefs, which was against protocol. The Director of Nursing (DON) and the Administrator acknowledged that not providing timely incontinent care and the use of two briefs could increase the risk of skin breakdown. Resident #58 was observed to have long, jagged fingernails, which he stated were not being checked as they should be during his scheduled showers. CNA #2 confirmed the condition of the resident's nails and acknowledged that they could cause scratches and potential infections. The Assistant Director of Nursing (ADON) and the Administrator confirmed that nail care should be performed during resident baths and showers, and that the CNAs were responsible for checking nails daily. Despite the resident's cognitive intactness, he required substantial assistance with personal hygiene, which was not adequately provided. Resident #59 also had long, jagged fingernails with a brown substance underneath, and he expressed that his fingernails had not been checked in a while. CNA #2 and Registered Nurse (RN) #1 confirmed the condition of the resident's nails and the potential for infection. The resident, who had impaired vision and required assistance with personal hygiene, did not receive the necessary nail care during his scheduled baths. The facility's failure to adhere to its policy on ADL care resulted in these deficiencies, as confirmed by staff interviews and observations.
Deficiency in Preventing Accident Hazards
Penalty
Summary
The facility failed to ensure a safe environment for residents by allowing smoking paraphernalia and medications to be accessible in resident rooms. Resident #22 was found with a cigarette box containing a cigarette and a used cigarette butt in his room, despite the facility's policy prohibiting residents from keeping smoking materials. The Director of Nursing and the Administrator acknowledged that the resident could have obtained cigarettes from outside the facility and emphasized the use of an honor system to manage smoking materials. The Administrator confirmed the risk of fire due to the presence of smoking materials in the resident's room. Resident #34 was observed with bottles of Rolaids, Magnesium, and Multivitamins on his bedside dresser, which he brought from home and self-administered without an order. The Registered Nurse confirmed that the resident should not have had medication in his room, as it could lead to double dosing and medication errors. The Administrator was unaware of the resident's possession and self-administration of these medications, acknowledging the potential risk of overmedication if the resident was also receiving the same medications from the nursing staff.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that medications were stored securely in a locked medication cart or storage room, as observed in two of the four medication carts used in the facility. During an observation, an unattended medication cart was found outside the dining room with a medicine cup full of a red liquid, a bottle of magnesium, Colace, and calcium sitting on top. The Assistant Director of Nurses confirmed that these medications should not have been left unattended, as it could lead to residents ingesting them accidentally. The Licensed Practical Nurse responsible for the cart admitted to leaving the medications unsecured while retrieving additional medication. In another instance, a Registered Nurse was observed leaving medication cards unsecured on a medication cart. The nurse placed medication cards, including Baclofen, Buspar, Augmentin, and Cyproheptadine, inside a narcotic binder but left the cart unattended with the card edges visible and accessible. Upon returning, the nurse acknowledged that leaving the medications unsecured was a hazard, as residents could have accessed them. The Director of Nurses confirmed that medications should never be left unattended on a cart.
Failure to Implement Enhanced Barrier Precautions and Infection Control Measures
Penalty
Summary
The facility failed to fully implement Enhanced Barrier Precautions (EBP) and follow infection control measures, affecting 11 residents on EBP and two specific residents. Observations revealed inadequate signage for EBP across different halls, with only a few rooms displaying the necessary signs. Interviews with staff, including CNAs, LPNs, and the RN/Infection Preventionist, indicated a lack of awareness and understanding of EBP, with some staff members having never heard of it or being unsure of its purpose. This lack of knowledge persisted despite an in-service conducted two months prior, as confirmed by the Director of Nurses and the Administrator. During the survey, it was observed that a CNA placed a soiled disposable bed pad on the floor while assisting a resident with a colostomy bag, which was acknowledged as an infection control concern by both the CNA and the Administrator. Additionally, an LPN failed to don a gown while administering medication via a PEG tube to a resident, despite the presence of an EBP sign on the door. The LPN admitted to missing the part of the in-service that covered the need for precautions with PEG medications, although the DON confirmed that staff had been in-serviced on this requirement. The facility's failure to implement EBP effectively was further highlighted by the discrepancy in the number of residents listed on EBP, which increased from four to eleven after the survey began. The Administrator acknowledged the need for auditing staff post-in-service to ensure proper implementation of EBP, which was not done, leading to the observed deficiencies.
Failure to Honor Resident's Beverage Preference
Penalty
Summary
The facility failed to honor a resident's choice for sweet tea with meals, as observed and confirmed through interviews and meal ticket reviews. Resident #44 expressed her preference for sweet tea, which had not been provided for over a month despite her requests. On two separate occasions, the resident received unsweetened tea with her meals, contrary to the meal ticket instructions that specified sweetened iced tea. The Dietary Manager confirmed that the meal ticket listed sweet tea, and acknowledged that the resident's preferences should be honored. Resident #44, who was cognitively intact with a BIMS score of 15, was admitted to the facility with a diagnosis of Chronic Obstructive Pulmonary Disease. The facility's policy on Resident's Rights and Quality of Life emphasizes the importance of self-determination and honoring resident choices. However, the facility's failure to provide the resident with her preferred sweet tea demonstrates a lapse in adhering to this policy, as confirmed by the Dietary Manager's acknowledgment of the oversight.
Failure to Address and Update Advance Directives
Penalty
Summary
The facility failed to ensure that advance directives were properly addressed or updated for three residents, leading to discrepancies in their code status. Resident #43's advance directive indicated a Do Not Resuscitate (DNR) order, but the resident was unaware of its meaning and expressed a desire to be a full code. Interviews revealed that the resident's cognitive status had improved since admission, and he was capable of making his own medical decisions. However, the facility did not reassess or update his advance directive to reflect his current wishes until it was brought to their attention. Resident #63 initially signed a DNR order upon admission when he was very ill, but later expressed a desire to change to full code as his condition improved. Despite this, there was a mismatch between the written advance directive and the electronic system, which incorrectly listed him as a full code. This discrepancy was acknowledged by the facility staff, who admitted it was an oversight that the advance directives did not match. Resident #84's advance directive was incomplete, with only the resident's name and date of birth filled out, and lacked any indication of the resident's code status. The form was erroneously signed by a physician without being properly completed. The facility admitted that this was a careless error, as the resident's code status had not been addressed upon admission, despite the resident being cognitively intact and capable of making such decisions.
Resident Information Privacy Breach
Penalty
Summary
The facility failed to maintain the confidentiality of resident information, as observed during a survey. On one of the survey days, a medication cart was found outside the dining room door with a visible list containing resident names, room numbers, code status, and information on whether they were on hospice or dialysis. This list was accessible to anyone passing by, violating the residents' right to privacy and confidentiality as outlined in the facility's policy. The Assistant Director of Nurses (ADON) confirmed the visibility of the resident list and acknowledged it as a privacy violation. The Licensed Practical Nurse (LPN) responsible for the cart admitted to leaving the list exposed while retrieving medications, recognizing it as a privacy issue. The Director of Nurses (DON) also confirmed that the exposure of resident information was a breach of privacy. The list included details of 22 residents from the B Hall and four from the A Hall.
Failure to Conduct Timely Background Check for New Hire
Penalty
Summary
The facility failed to ensure that a new employee, specifically a Registered Nurse (RN) Unit Manager, had a current background check completed prior to employment. The facility's policy mandates that background checks must be conducted on all applicants offered employment to ensure workplace productivity, safety, and security. However, the RN Unit Manager was hired with a background check that was outdated, having been completed over two years prior to her hiring date. Interviews with the Administrator, Assistant Director of Nurses (ADON), and Human Resources confirmed the oversight, acknowledging that the background check should have been updated within two years of the hire date to ensure there were no disqualifying events or allegations against the staff member.
Failure to Update Resident Care Plan with Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that a resident's comprehensive care plan was revised and updated, as required, for one of the sampled residents. The resident, who was admitted with a medical diagnosis including Huntington's Disease, was observed on two separate occasions lying in bed with a raised perimeter air mattress. This mattress was intended to prevent the resident from rolling out of bed. However, a review of the resident's Fall Care Plan revealed that it had not been revised to include the use of the secured perimeter air mattress. Interviews with the Director of Nursing and the Administrator confirmed that the care plan should have been updated to reflect the use of the mattress as part of the resident's fall prevention strategy. The facility's policy mandates that care plans be developed by the interdisciplinary team and revised as needed according to the resident's status or changes, which was not adhered to in this case.
Failure to Administer IV Antibiotics as Ordered
Penalty
Summary
The facility failed to adhere to nursing standards of practice for a resident who had a physician order for intravenous (IV) antibiotics. The Medication Administration Record (MAR) for the resident indicated an order for Meropenem to be administered intravenously for five days. However, the MAR was only initialed for two days, with no documentation for the remaining three days, suggesting the medication was not administered as prescribed. Interviews with the resident and nursing staff, including the Registered Nurse (RN) Unit Manager and a Licensed Practical Nurse (LPN), confirmed the lack of documentation and administration for those days. The resident, who was admitted with a urinary tract infection and dependence on renal dialysis, was cognitively intact as per the Minimum Data Set (MDS) assessment. The Director of Nursing (DON) confirmed that without documentation, the medication was considered not given. The absence of a facility policy on Standards of Practice was noted, and the failure to administer the antibiotic as ordered could potentially worsen the resident's infection, although this was not explicitly stated in the report.
Failure to Assess and Obtain Consent for Bed Rails
Penalty
Summary
The facility failed to properly assess and obtain consent for the use of bed rails for two residents, leading to deficiencies in their care. Resident #33, who was admitted with Huntington's Disease, was observed with half side rails up on both sides of her bed, despite a clinical evaluation indicating that side rails should not be utilized. The Director of Nursing (DON) was unaware of the bed rails' presence, and the Assistant Director of Nursing (ADON) confirmed that no consent was signed for their use. The resident was on hospice care, and the bed rails were mistakenly left in place when a new bed was delivered. Resident #60, who has Type 2 Diabetes Mellitus, gait and mobility abnormalities, and a mixed receptive-expressive language disorder, was also observed with half side rails up on both sides of the bed. The Registered Nurse (RN) and DON confirmed that the bed rails were not supposed to be in that position, as the resident's assessment indicated that side rails should not be used. The Administrator acknowledged that the staff should have identified the incorrect positioning of the bed rails. Both residents' records lacked the necessary consent for the use of bed rails, highlighting a failure in the facility's assessment and consent processes.
Deficiency in Food Quality and Resident Satisfaction
Penalty
Summary
The facility failed to provide food that met the residents' preferences and served meals in an unappealing and unpalatable manner for four residents. Resident #20, who was on a renal diet, expressed dissatisfaction with the repetitive and unappetizing meals, such as a thick, gray chicken breast on a dry bun and mushy pasta salad. Despite being aware of the resident's dislikes, the Dietary Manager and Registered Dietician did not intervene to offer alternative meal options. Resident #20 was cognitively intact and had been admitted with a urinary tract infection and dependence on renal dialysis. Resident #27 reported that the food was terrible, with chicken too hard to chew and hash-browns that were still frozen inside. When requesting an alternate meal, the resident received the same meal again. The resident, who was cognitively intact and had Type 2 Diabetes Mellitus, had complained to aides but was unsure of whom else to inform. Similarly, Resident #43, who had Alzheimer's Disease, complained about the chicken being overcooked and difficult to chew, and despite multiple complaints to the cooks, no improvements were made. Resident #50 also experienced issues with food quality, receiving meals that were cold and difficult to chew, such as frozen hash-browns and overcooked chicken. The resident, who was cognitively intact and had Chronic Obstructive Pulmonary Disease, reported these issues to aides but received no resolution. The facility's Administrator and Dietary Manager acknowledged ongoing food complaints, which had not been addressed since the Dietary Manager's maternity leave, leading to a lapse in food committee meetings and unresolved resident concerns.
Failure to Assist Resident with Toileting
Penalty
Summary
The facility failed to uphold a resident's right to dignity and respect when a staff member refused to assist with toileting. During an observation and interview, a resident who was unable to walk and required assistance with toileting expressed frustration about being told by Certified Nursing Assistants (CNAs) to use her brief instead of being helped to the bathroom. The resident, who had no cognitive deficits and used a sit-to-stand lift for toileting, reported that CNAs often told her they didn't have time to assist her and suggested she use her brief instead. This incident was directly observed when a CNA refused to help the resident to the bathroom, despite the resident's request and the presence of a state agency representative. Interviews with facility staff, including a Licensed Practical Nurse (LPN) and the Director of Nursing (DON), confirmed that the CNA's actions were inappropriate and did not align with the facility's policy on resident dignity. The DON and the facility Administrator both acknowledged that refusing to assist a resident with toileting and suggesting they use their brief was unacceptable behavior. The resident's admission records indicated she had reduced mobility and required assistance with personal care, further emphasizing the need for staff to provide the necessary support when requested.
Failure to Implement ADL Care Plans for Residents
Penalty
Summary
The facility failed to implement Activities of Daily Living (ADL) care plans for two residents, leading to deficiencies in personal hygiene care. Resident #1, who had a self-care deficit related to decreased functional abilities, was observed with facial hair that had not been removed as per her care plan. Despite her expressed desire to have the facial hair removed, it was confirmed by an LPN that this task was not completed on her last bath day. The resident's care plan required extensive assistance with personal hygiene, including cueing, supervision, and assistance with ADLs, which was not adhered to. Similarly, Resident #8, who also had a self-care deficit, was found with unshaven facial hair and had not received oral care since admission. The resident expressed a need for a toothbrush and toothpaste, which had not been provided, resulting in visible white substance between his teeth and gums. The CNA assigned to him confirmed the lack of assistance with mouth care, and the LPN acknowledged the oversight in providing daily mouth care and shaving. The Director of Nursing confirmed that the care plans for both residents were not followed, as they should have been shaved on their scheduled bath days and provided with necessary oral care supplies.
Deficiencies in Personal Care for Residents
Penalty
Summary
The facility failed to provide adequate personal care for two residents, specifically in the areas of oral hygiene and shaving. Resident #1, who has no cognitive deficits and requires assistance with personal care due to reduced mobility, was observed with unwanted facial hair that had not been removed as per her preference. Despite having a care plan that included shaving during her bath on 06/10/24, the CNAs did not perform this task, as confirmed by the CNA Bath & Shower Report. Resident #8, who has moderate cognitive deficits and requires supervision for personal hygiene, was found with significant facial hair and had not been provided with a toothbrush or toothpaste since his admission over a week prior. He expressed a desire to be shaved more frequently, as he used to do at home, and had not brushed his teeth since arriving at the facility. The CNAs were responsible for providing daily mouth care and shaving during scheduled bath times, but these tasks were not completed for Resident #8, as confirmed by the CNA Bath & Shower Report and interviews with staff. The facility's policy on Activities of Daily Living (ADLs) requires that care be provided according to accepted standards and resident preferences. However, the observations and interviews revealed that the facility did not adhere to these standards for Residents #1 and #8, resulting in unmet personal care needs. The Director of Nursing confirmed that the deficiencies in shaving and oral care should have been addressed during the residents' regular bath times.
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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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