Edgewood Health & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Byram, Mississippi.
- Location
- 205 Byram Parkway, Byram, Mississippi 39272
- CMS Provider Number
- 255103
- Inspections on file
- 26
- Latest survey
- March 2, 2026
- Citations (last 12 mo.)
- 9 (4 serious)
Citation history
Health deficiencies cited at Edgewood Health & Rehabilitation during CMS and state inspections, most recent first.
A resident with dementia and recent right femur fracture, requiring wheelchair use and one-person assist for stand-pivot transfers, was subjected to verbally abusive, demeaning, and intimidating treatment by two CNAs during care, while repeatedly requesting help and complaining of pain. Two additional CNAs were present for part of the interaction, heard staff telling the resident to get up and that she was not handicapped, observed an unsuccessful attempt to stand, and left without reporting the incident. The resident’s representative later reported the abuse with an audio recording capturing the resident crying, screaming, complaining of rough treatment, and begging staff to stop while staff mocked and laughed. RNs, the DON, and a lead CNA who reviewed the recording described the language and tone as cruel, degrading, and malicious, yet the allegation was not reported to the SA within required timeframes, no immediate investigation occurred, and facility administration did not promptly implement protective measures, leading to an Immediate Jeopardy finding under F600.
A facility failed to report an allegation of verbal abuse involving a resident to the State Agency within the required 2-hour timeframe. A resident’s representative reported the alleged verbal abuse, supported by an audio recording, to RNs and requested to speak with administration. The RN supervisor promptly notified the DON, who then notified the Administrator, but the allegation was not reported to the State Agency until two days later, well beyond policy and regulatory requirements. Interviews with the DON, Administrator, RN supervisor, and the resident’s representative confirmed the internal notification times and the delayed external reporting, resulting in a deficiency for failure to timely report alleged violations.
A resident’s representative reported an allegation of verbal abuse, supported by an audio recording of staff cursing at the resident while the resident screamed. An RN supervisor promptly notified the DON and the Administrator, and staff who heard the recording considered the interaction abusive, but no immediate interviews of staff or other residents were conducted, no comprehensive resident assessments were documented, and protective interventions were not implemented beyond moving the resident to another unit. The DON did not come on-site until the following day, when only a single interview with the resident was completed, and contact with the representative and broader staff and resident interviews did not occur until two days after the initial report, during which time staff alleged to be involved continued providing care. The facility’s actions did not follow its abuse policy requiring prompt investigation, suspension of suspected staff, and protection of residents, leading surveyors to cite Immediate Jeopardy for failure to investigate alleged violations under 42 CFR 483.12(c)(2).
Facility administration failed to timely report an allegation of verbal abuse supported by an audio recording, did not immediately remove the alleged CNA perpetrator from resident contact, and delayed initiating an investigation. A resident’s representative reported the incident to nursing staff, who notified the DON and Administrator, but the allegation was not reported to the State Agency within required timeframes, and no staff interviews were conducted the day the allegation was received. The only immediate action taken was moving the resident to another unit at the family’s request, while the alleged CNA continued working until later termination, despite an existing abuse policy and an Administrator job description requiring compliance with reporting and investigative requirements.
Two residents who were dependent for bed mobility and required q2h repositioning did not receive timely turning and repositioning assistance in accordance with facility policy and standards of care. One resident with a history of stroke, dysphagia, and severely impaired cognition remained on her back for approximately five hours despite being care-planned for q2h turns, with the assigned CNA confirming only one repositioning earlier in the morning. Another alert and oriented resident with CHF and cervical spondylosis reported not being turned since early morning, and the CNA acknowledged that the first repositioning of the day occurred late in the morning and that she was unaware of any earlier turns. The RN Supervisor, who had responsibility for both residents during the morning, stated he had not checked on one resident and was unaware of the missed repositioning, describing the delay in care as a communication issue, while facility leadership stated their expectation that staff provide q2h and PRN repositioning to prevent discomfort and skin integrity damage.
A deficiency was cited when surveyors found that medications on one medication cart were not stored and labeled correctly, including Restasis eye drop vials placed inside an Albuterol nebulizer solution package labeled for a resident. The facility’s storage policy did not address placing one medication inside another’s packaging. A resident with a history of stroke, dysphagia, and severely impaired cognition had a family representative who observed a nurse enter the room to give a nebulizer treatment using a vial that was clearly not the correct medication, and the error was identified before administration.
A resident dependent on staff for mobility and transfers due to quadriplegia was injured during a transfer when a CNA attempted to use a mechanical lift without the required assistance of a second staff member and failed to lock the Geri-recliner or open the lift base. This resulted in the resident falling and sustaining a rib fracture, despite clear care plan instructions and staff training on proper transfer procedures.
Two residents experienced preventable accidents due to staff failing to follow established safety protocols. In one case, a dependent resident was transferred using a mechanical lift by only one CNA, resulting in a fall and rib fracture. In another case, a resident's wheelchair tipped over in a facility van during transport because staff had not received proper training on the securement system. Both incidents involved residents with significant physical or cognitive impairments and were confirmed by staff interviews and documentation.
A resident with severe cognitive impairment was transported in a facility van by two CNAs who had not received formal training or competency checkoff on the van's securement system. During the trip, the resident's wheelchair tipped over backwards onto the van floor. The CNAs assisted the resident, who was not injured, back to an upright position. Review of facility policy and staff files confirmed a lack of documented training or competency verification for staff performing resident transportation.
A resident with severe cognitive impairment and no prior history of wandering exited the facility unsupervised after a non-English-speaking lawn service worker held the front door open, unable to interpret posted warnings. The resident was found in the parking lot by a visitor after being outside for several minutes, highlighting a lapse in supervision and environmental safety protocols.
A resident with moderate cognitive impairment and a history of bipolar disorder received a new physician order for an auto-adjusting CPAP machine, but the care plan was not updated to reflect the new settings or equipment. The care plan continued to reference outdated CPAP parameters, and the IDT did not review or revise the plan to address the resident's updated respiratory therapy needs.
A resident with moderate cognitive impairment did not receive a physician-ordered C-Pap machine for several months due to the facility's failure to promptly transcribe and act on the order. The order was known to facility leadership but was not authorized or provided until a significant delay had occurred.
Two residents in an LTC facility were subjected to abuse by CNAs. One resident experienced physical abuse from a CNA who struck her during care, while another resident was verbally abused by a different CNA who made belittling and inappropriate remarks. Both residents had cognitive impairments, and the incidents were reported by a roommate and confirmed through facility investigations.
A resident with Alzheimer's and muscle weakness was left unable to eat during a meal due to unopened drink and out-of-reach utensils, contrary to her ADL care plan. The LPN and DON confirmed the oversight, acknowledging the necessity of staff assistance for meal setup.
A resident with moderate cognitive impairment was left unable to feed herself during a meal due to unopened drink and out-of-reach utensils. The facility's policy on meal assistance was not followed, as confirmed by the DON and Administrator.
Two residents were served meals that did not match the posted menu or facility recipes, leading to dissatisfaction. A club sandwich was listed, but residents received sandwiches lacking expected ingredients. The facility's policy required adherence to the menu, but dietary staff were unsure of the correct ingredients.
A resident with schizophrenia and vascular dementia was discharged from an LTC facility without a proper discharge notice. The notice lacked essential details such as the discharge plan, reason, and location, and was received late by the resident's representative. The resident was transferred to a hospital's behavioral health unit due to inappropriate behavior before the 30-day notice period ended. Staff interviews revealed a lack of experience in preparing discharge letters.
A resident experienced knee pain and a subsequent femoral fracture after a transfer incident involving a dead lift battery, leading to a manual transfer by CNAs. Despite the resident's complaints and a sitter's report, the LPN did not notify the physician or resident representative, violating facility policy. The resident had a history of hemiplegia and was cognitively intact.
A resident with a history of osteoporosis and hemiplegia experienced a failure in pain management when staff did not follow the care plan during a transfer, resulting in a fracture. The care plan required documentation and administration of pain medication, which was not done. The DON and Administrator confirmed the lapse in following the care plan.
A resident with a history of osteoporosis and hemiplegia suffered a right femur fracture during a transfer when the mechanical lift's battery failed. Despite the facility's no-lift policy, two CNAs manually transferred the resident, leading to the injury. The incident was not reported or investigated immediately, contrary to facility policy.
A resident with a history of osteoporosis and hemiplegia experienced pain after a manual transfer due to a dead lift battery. Despite complaints of pain, the LPN did not administer pain medication, violating the facility's pain management policy. The resident, cognitively intact, received a routine pain patch the following day, but no immediate relief was provided.
The facility failed to maintain proper food storage and labeling practices in the kitchen, as observed during an inspection. Issues included unlabeled and exposed food items, overly ripe produce with biological growth, and improperly stored dry goods. The Dietary Manager acknowledged these deficiencies, attributing them to a lack of oversight by the weekend cook. The Administrator was informed and expected daily monitoring of food safety practices.
A resident with moderately impaired cognition was placed in a wheelchair harness vest without a proper assessment or evaluation, contrary to facility policy. The vest was introduced by a family member and used without completing the necessary restraint decision form. The DON acknowledged the oversight, and the PT confirmed the lack of recent evaluation for the resident's posture.
A facility failed to properly store respiratory equipment for a resident, as required by their policy. Observations revealed that oxygen tubing was undated and not stored in a plastic bag when not in use. Interviews with LPNs and the DON confirmed the policy requirements, but staff admitted to not having seen the necessary storage bags. The resident had a diagnosis of Metabolic Encephalopathy and required oxygen for shortness of breath.
The facility failed to maintain an effective QAPI committee, resulting in a re-cited deficiency related to restraint management. A resident was not assessed for a least restrictive restraint, and the facility did not obtain a physician order for the use of a restraint for one of the residents reviewed.
A resident with quadriplegia was left unfed during a meal when a CNA was interrupted by an LPN to attend a meeting. The resident, who was dependent on staff for eating, expressed feeling disrespected and hungry as her food became cold. The CNA confirmed the incident, and the DON acknowledged the nurse's actions were inappropriate.
A resident with cognitive impairment accessed an unlocked medication cart and consumed Lactulose liquid due to the facility's failure to implement a care plan. The resident, known for rummaging and drinking inappropriate substances, was not adequately supervised, and the care plan interventions were not followed. The incident highlighted the need for staff to adhere to care plans to prevent such occurrences.
A resident with cognitive impairments accessed an unlocked medication cart and ingested Lactulose, highlighting a failure in maintaining a safe environment. The resident, known for rummaging behaviors, was able to open the cart due to an LPN's oversight. This incident was classified as Immediate Jeopardy and Substandard Quality of Care.
A facility failed to notify a resident's representative about changes in the resident's condition, specifically scratches on the chest, despite a policy requiring such communication. The resident, with severe cognitive impairment and multiple health conditions, had scratches noted during a body audit by the DON, who forgot to inform the representative. The oversight was discovered when the representative visited and filed a grievance.
The facility did not report an allegation of non-consensual sexual contact between residents to the State Agency within the required timeframe. An LPN observed inappropriate touching by a resident with dementia on two occasions and documented the incidents, but the RN Supervisor was not informed of the physical contact. The Social Service Director later reported the incidents to the Interdisciplinary Team, but the DON did not report them to the State Agency. The resident involved had a history of schizophrenia and moderate cognitive impairment.
A resident with wandering behaviors ingested a cleaning solution from an unsecured housekeeping cart. The facility's policy required hazardous chemicals to be locked when not in use, but this was not followed. The resident, with a history of dementia and behavioral disturbances, accessed the cart and consumed the solution, leading to immediate medical intervention.
The facility failed to manage and treat pain complaints for two residents when there was no licensed nurse available on their unit for approximately six hours and 45 minutes. One resident reported severe pain and did not receive her medication until later that night, while another resident with surgical-related pain was also left untreated. Staff interviews revealed a break in communication and staffing issues, leading to the deficiency.
Failure to Prevent, Report, and Investigate Verbal Abuse of a Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s right to be free from abuse and to protect residents from verbal and mental abuse after an allegation was reported. The facility’s own Abuse Policy defined verbal abuse as the use of disparaging and derogatory language and mental abuse as including humiliation, harassment, and threats of punishment or deprivation, and stated that residents were not to be subjected to abuse by anyone, including staff. Despite this, on the evening of 2/10/26, a resident was subjected to disparaging, demeaning, and derogatory language and deliberate actions intended to intimidate the resident by two CNAs during the provision of care. The resident repeatedly requested assistance and complained of pain, but was mocked, scorned, criticized, and insulted by the CNAs, and her complaints of discomfort, pain, and rough treatment were dismissed. The resident involved had been admitted with diagnoses including encounter for other orthopedic aftercare, fracture of the right femur, and dementia, and had a BIMS score of 11 indicating moderate cognitive impairment. The resident required a wheelchair for mobility, partial/moderate assistance for dressing and bed mobility, and one-person assistance for stand-pivot transfers with weight bearing as tolerated and caution due to right hip surgery. The resident’s care plan directed staff to provide assistance as needed for ADLs and transfers, and to anticipate and meet needs based on physical or non-verbal indicators of discomfort or distress. On the evening of 2/10/26, CNA #1 was assigned to the resident’s room and, along with CNA #2, provided care during which the abusive interaction occurred. Two other CNAs were present for part of the interaction, heard CNA #1 telling the resident to get up and that she was not handicapped, saw the resident attempt unsuccessfully to stand, and then left the room without reporting what they had heard. On 2/14/26 at approximately 8:40 AM, the resident’s representative reported an allegation of verbal abuse, supported by an audio recording, to the RN Supervisor. RN #1 and RN #2 listened to the recording with the resident and representative and described it as demeaning, degrading, cruel, and shocking, with the resident heard crying, screaming, complaining of pain and rough treatment, and begging the CNAs to stop while the CNAs mocked and laughed at her. RN #2 notified the DON at approximately 8:50 AM, and the DON notified the Administrator at approximately 9:01 AM. However, no interviews were conducted on 2/14/26, and the DON and Administrator did not come to the facility that day. The facility did not report the allegation to the State Agency within the required two-hour timeframe and did not begin a formal investigation until 2/15/26. During the investigation, the Lead CNA Supervisor and DON listened to the recording, recognized the voices of the resident and the two CNAs, and confirmed that the language and tone used were abusive, derogatory, demeaning, and malicious. CNA #2 later confirmed being present in the room throughout the incident and acknowledged being "guilty by association" for not reporting the abuse. The facility’s failure to immediately report, protect, and investigate after the allegation was made led to a finding of Immediate Jeopardy and Substandard Quality of Care under F600. The State Agency determined that Immediate Jeopardy began on 2/14/26 when the facility failed to protect residents from abuse, failed to report the alleged abuse timely, failed to promptly investigate the allegations, and administration failed to implement and enforce the facility’s abuse policies. The facility’s failure to report, protect, and investigate abuse placed all residents at risk in a situation likely to cause serious injury, serious harm, serious impairment, or death. The abusive conduct toward the resident, combined with the delayed response and lack of immediate protective measures after the allegation was reported, constituted the core deficiency identified by surveyors.
Removal Plan
- Resident #1 was moved from Unit A to Unit B at the request of the family after discussion with Registered Nurse #1.
- The Director of Nursing interviewed Resident #1 regarding the allegations of alleged abuse, and she denied any such happenings.
- The Director of Nursing assessed the resident for any physical or emotional effects.
- Psychosocial support was initiated and conducted for 72 hours by the Social Services Director.
- Resident #1 was referred to the Psychiatric Nurse Practitioner for evaluation.
- The Director of Nursing, Staff Development, and Lead CNA provided education with all staff regarding the Facility Abuse Policy and Procedures.
- A Corporate Nurse conducted an in-service with the Director of Nursing and Facility Administrator regarding abuse allegations, investigations, and proper reporting timeliness.
- CNA #1 was contacted multiple times to be terminated but did not return phone calls.
- CNA #2 was terminated upon review of the recording due to her voice being recognized using aggressive language.
- All staff will be educated on Abuse Policy and Procedure as well as the timeline for reporting and investigation of allegations of abuse by the Director of Nursing, Staff Development Nurse, Lead CNA, and RN Supervisor.
- No staff will be allowed to work until in-serviced.
- An AD HOC Quality Assurance meeting was held to review the plan for removal of the Immediate Jeopardy tag.
- The policy was reviewed with no changes.
Failure to Timely Report Verbal Abuse Allegation to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of verbal abuse to the State Agency (SA) within the required two-hour timeframe, as required by federal regulation and the facility’s own Abuse Policy and Procedure. The policy dated 1/24/22 states that any alleged incident reported must be investigated and reported to the state within two hours of knowledge of the alleged incident. On 2/14/26 at approximately 8:40 AM, the resident representative (RR) for Resident #1 reported an allegation of verbal abuse, supported by an audio recording, to facility nursing staff. The RR requested to speak with administration and provided access to the recording to two RNs. Record review and interviews show that the allegation was promptly communicated internally but not reported externally within the required timeframe. RN #2, the RN Supervisor on Unit A, notified the DON by telephone at approximately 8:50 AM on 2/14/26. The DON then notified the Administrator at approximately 9:01 AM the same morning. Despite this, the allegation of abuse was not initially reported to the SA until 2/16/26 at 11:30 AM, well beyond the two-hour reporting requirement. The facility’s own investigation documentation dated 2/19/26 confirms these times and the delay in reporting. Interviews with the DON, Administrator, RR, and RN #2 corroborate the sequence of events and the delay. The DON acknowledged being notified of the allegation on 2/14/26 at approximately 8:50 AM and stated she reported the allegation to the SA on 2/16/26 at 11:30 AM. The Administrator confirmed he was notified by the DON on 2/14/26 at about 9:00 AM and that the allegation was not reported to the SA until 2/16/26. The RR confirmed she reported the verbal abuse allegation and shared the recording with nursing staff on the morning of 2/14/26. The Administrator confirmed that the facility failed to report the allegation of abuse within the required timeframe according to state and federal requirements, resulting in a deficiency at 42 CFR 483.12(c)(1)(4) for failure to timely report alleged violations.
Removal Plan
- Move Resident #1 from Unit A to Unit B at the request of the family after discussion with the Registered Nurse.
- Interview Resident #1 regarding the allegations of abuse.
- Assess Resident #1 for any physical or emotional effects related to the allegations.
- Provide psychosocial support for 72 hours by the Social Services Director.
- Refer Resident #1 to the Psychiatric Nurse Practitioner for evaluation.
- Provide education to all staff regarding the Facility Abuse Policy and Procedures.
- Conduct an in-service with the Director of Nursing and Facility Administrator regarding abuse allegations, investigations, and proper reporting timeliness.
- Contact CNA #1 to proceed with termination.
- Terminate CNA #2 upon review of the recording due to use of aggressive language.
- Educate all staff on the Abuse Policy and Procedure and the timeline for reporting and investigation of allegations of abuse.
- Do not allow staff to work until they have been in-serviced.
- Hold an AD HOC Quality Assurance meeting to review the plan for removal of the Immediate Jeopardy tag.
- Review the policy.
Failure to Timely Investigate Verbal Abuse Allegation and Implement Protective Measures
Penalty
Summary
The deficiency involves the facility’s failure to promptly and thoroughly investigate an allegation of verbal abuse and to implement immediate protective measures after the allegation was reported. On 2/14/26 at approximately 8:40 AM, the resident representative (RR) for Resident #1 reported an allegation of verbal abuse to the RN Supervisor (RN #2), including an audio recording made on the resident’s cell phone that captured staff cursing at the resident while the resident was heard screaming. RN #2 notified the DON by telephone at approximately 8:50 AM, and the DON notified the Administrator at approximately 9:01 AM. Staff who heard the recording, including RN #1 and RN #2, considered the interaction abusive and were able to identify the voice of Resident #1, though they did not initially recognize the staff voices. Despite this, the Administrator and DON did not come to the facility on 2/14/26, and no formal investigation was initiated that day. The facility’s own Abuse Policy and Procedure, dated 1/24/22, required that all alleged violations be thoroughly investigated under the direct supervision of the Administrator, that all necessary steps be taken to prevent further potential abuse while the investigation was in progress, and that any employee suspected of abuse be suspended pending investigation. The policy also required that residents be protected from harm through frequent supervision and reassurance during and after the investigation. Contrary to this policy, on 2/14/26 there were no interviews of staff or other residents, no documented resident assessments for signs or symptoms of abuse, and no protective interventions implemented beyond moving Resident #1 to another unit. The DON stated she had instructed RN #1 to follow up on 2/14/26 at approximately 10:00 AM but was not aware of any interviews or other investigative steps taken that day. RN #1 confirmed that she did not conduct any interviews, did not assess any residents, and did not place any interventions in place to protect residents on 2/14/26. The investigation did not substantively begin until 2/15/26 and 2/16/26. The DON reported to the facility on 2/15/26 at approximately 10:00 AM and conducted a single interview with Resident #1 and attempted, unsuccessfully, to locate the recording on the resident’s cell phone; she did not contact the RR or conduct any other interviews that day. On 2/16/26, the DON contacted the RR for the first time since the initial notification, obtained the audio recording at approximately 11:16 AM, and, together with the Lead CNA Supervisor, listened to it and identified the voices of Resident #1, CNA #1, and CNA #2. The DON also determined that CNA #2 had been present during the incident and ascertained that the incident date was 2/10/26. Interviews of other residents were delegated to the Social Services Director, who reported interviewing four residents on one hall on 2/19/26. Throughout the period from 2/14/26 until 2/16/26, the facility did not immediately suspend all staff suspected of involvement, and staff alleged to be involved continued to provide resident care, despite the existence of an audio recording that facility staff and administration validated as capturing abusive language toward Resident #1. The Administrator confirmed that he had delegated responsibility for investigating the allegation to the DON and was unaware of any staff interviews conducted prior to 2/16/26. Multiple staff, including the DON, RN #1, RN #2, and the Social Services Director, acknowledged that failure to thoroughly investigate an allegation of abuse could result in continued abuse of residents. The State Agency determined that the facility’s failure to initiate a timely investigation and implement protective measures after the allegation was reported on 2/14/26 created the likelihood of continued abuse of Resident #1 and other residents and placed them in a situation likely to cause serious harm, serious injury, serious impairment, or death. This failure resulted in Immediate Jeopardy and Substandard Quality of Care at 42 CFR 483.12(c)(2), Investigation of Alleged Violations, with an initial scope and severity level of J.
Removal Plan
- Moved Resident #1 from Unit A to Unit B at the request of the family after discussion with RN #1.
- DON interviewed Resident #1 regarding the allegations; Resident #1 denied the allegations.
- DON assessed Resident #1 for any physical or emotional effects.
- Psychosocial support was initiated and provided for 72 hours by the SSD.
- Referred Resident #1 to the Psychiatric Nurse Practitioner for evaluation.
- DON, Staff Development, and Lead CNA provided education to all staff regarding the Facility Abuse Policy and Procedures.
- Corporate Nurse conducted an in-service with the DON and Facility Administrator regarding abuse allegations, investigations, and proper reporting timeliness.
- CNA #1 was contacted multiple times to be terminated due to being a no show and not having worked; CNA #1 did not return phone calls.
- CNA #2 was terminated upon review of the recording due to her voice being recognized using aggressive language.
- Educated all staff on the Abuse Policy and Procedure and the timeline for reporting and investigation of allegations of abuse; no staff were allowed to work until in-serviced.
- Held an AD HOC QA meeting to review the plan for removal of the IJ tag.
- Reviewed the policy with no changes.
Failure to Timely Report and Investigate Verbal Abuse Allegation and Remove Alleged Perpetrator
Penalty
Summary
The deficiency involves the facility’s failure to administer operations in a way that ensured timely and effective response to an allegation of verbal abuse. A resident representative reported an allegation of verbal abuse involving Resident #1 on 2/14/26 at approximately 8:40 AM to an RN supervisor, providing an audio recording in which staff were heard cursing at the resident while the resident was heard screaming. The RN supervisor notified the DON at approximately 8:50 AM, and the DON notified the Administrator at approximately 9:01 AM. Despite this, the Administrator, who acknowledged awareness of state and federal reporting timeframes and whose job description includes ensuring reportable events are reported within regulatory requirements, did not ensure the allegation was reported to the State Agency within the required timeframes. The facility also failed to implement immediate protective measures and to promptly initiate an investigation after the allegation was reported. Staff schedules and interviews showed that the alleged perpetrator, CNA #2, continued to work in the facility after the allegation was reported on 2/14/26 and remained on duty until 2/16/26 at approximately 11:16 AM, when employment was terminated. Staff confirmed that neither the Administrator nor the DON came to the facility on 2/14/26 and that no staff interviews were conducted that day. The only intervention implemented on 2/14/26 was relocating Resident #1 to another unit at the request of the resident representative. Record review indicated that the facility had an Abuse Policy and Procedure requiring residents to be free from verbal, physical, mental, and sexual abuse and requiring that allegations of abuse be reported and investigated in accordance with regulatory requirements. The facility’s own investigation documented that the allegation was not reported to the State Agency until 2/16/26 and that staff interviews did not begin until 2/16/26. The Administrator confirmed being notified of the allegation on 2/14/26 at approximately 9:00 AM and confirmed awareness of the regulatory timeframes for reporting allegations of abuse. The facility did not have a separate Administration Policy, but the Administrator’s job description required leading operations in accordance with regulations and ensuring reportable events such as alleged abuse are reported to the correct entity within required timeframes.
Removal Plan
- Moved Resident #1 from Unit A to Unit B at the request of the family after discussion with Registered Nurse #1.
- Director of Nursing interviewed Resident #1 regarding the allegations of abuse, and she denied any such happenings.
- Director of Nursing assessed Resident #1 for any physical or emotional effects.
- Provided psychosocial support for 72 hours by the Social Services Director.
- Referred Resident #1 to the Psychiatric Nurse Practitioner for evaluation.
- Director of Nursing, Staff Development, and Lead CNA provided education to all staff regarding the Facility Abuse Policy and Procedures.
- Corporate Nurse conducted an in-service with the Director of Nursing and Facility Administrator regarding abuse allegations, investigations, and proper reporting timeliness.
- Contacted CNA #1 multiple times to proceed with termination.
- Terminated CNA #2 upon review of the recording due to use of aggressive language.
- Educated all staff on the Abuse Policy and Procedure and the timeline for reporting and investigation of allegations of abuse.
- Prohibited staff from working until in-serviced.
- Held an ad hoc Quality Assurance meeting to review the plan for removal of the Immediate Jeopardy tag.
- Reviewed the policy with no changes.
Failure to Reposition Dependent Residents per Two-Hour Standard of Care
Penalty
Summary
The deficiency involves the facility’s failure to provide turning and repositioning assistance according to standards of care and facility policy for two dependent residents who required ADL support. The facility’s ADL CARE POLICY dated August 2023 states that residents are to receive appropriate treatment and services to ensure all ADL needs are met daily. For Resident #1, observations on 1/12/26 at 9:30 AM showed the resident resting in bed on her back with the head of the bed elevated, with a family member present. At 2:00 PM, the family member reported she had been in the room continuously since before 9:30 AM and that the resident had not been turned or repositioned during that time. CNA #2, assigned to Resident #1 on the 7:00 AM–3:00 PM shift, confirmed at 2:56 PM that she had turned/repositioned the resident only once prior to 9:30 AM and acknowledged that the resident was supposed to be turned every two hours while in bed. Record review showed Resident #1 had diagnoses including cerebral infarction and dysphagia, severely impaired cognitive skills, and was assessed as dependent for bed mobility. For Resident #2, on 1/12/26 at 11:15 AM, observation and interview revealed the resident was lying on his back in bed, alert and oriented, reporting bilateral leg discomfort and stating he had not been repositioned since approximately 5:00 AM when a male CNA turned him onto his back. At 11:22 AM, CNA #1 entered and repositioned him onto his left side with a foam wedge, stating this was the first time she had turned him that day. In a 3:22 PM interview, CNA #1 stated the resident required repositioning every two hours and that she did not know when he had last been turned before 11:22 AM. The RN Supervisor, interviewed at 3:30 PM, stated he had been responsible for the care of both residents until approximately noon, had arrived at about 6:43 AM, and was not aware that Resident #2 had not been turned during the 7:00 AM–3:00 PM shift until 11:22 AM, nor that Resident #1 had not been turned for approximately five hours. He attributed the postponement of care to lack of communication and acknowledged he had not checked on Resident #2. The Administrator and DON both stated their expectations that nurses and RN Supervisors supervise care and that residents be turned/repositioned every two hours and as needed to avoid discomfort and damage to skin integrity. Record review for Resident #2 showed admission with diagnoses including congestive heart failure and cervical region spondylosis with myelopathy.
Improper Medication Storage and Labeling on Medication Cart
Penalty
Summary
Surveyors identified a deficiency in the facility’s medication storage and labeling practices involving one of three medication carts, specifically the 400 Hall medication cart. The facility’s written policy on medical supply storage, dated March 2011, did not address the practice of storing one medication inside the packaging of another medication. A Medication Error Report dated 12/29/25 documented that individual Restasis vials were found inside a nebulizer medication box, and a family member reported that the wrong vial had been brought into a resident’s room. The Administrator stated he expected nurses to maintain accurate storage of medications to ensure safe administration and acknowledged that storing one medication in the box of a different medication could lead to administration of the wrong medication. The DON confirmed that on 12/29/25 she was notified by the family of a resident that a nurse had entered the resident’s room with an incorrect vial for a nebulizer treatment. During her investigation, she found multiple vials of Restasis eye drops stored inside an Albuterol Sulfate Inhalation Solution package labeled with the resident’s name. The resident involved had been admitted with diagnoses including cerebral infarction (stroke) and dysphagia, and an MDS assessment dated 11/12/25 documented that the resident was rarely or never understood and had severely impaired cognitive skills for daily decision making. The resident’s representative reported that when the nurse entered the room and announced she was going to administer a nebulizer treatment for congestion, the representative observed that the vial was obviously not the correct medication and pointed this out, after which the nurse left the room without placing the medication into the nebulizer unit.
Failure to Follow Care Plan for Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when the facility failed to implement a comprehensive, person-centered care plan for a resident who required assistance with activities of daily living due to quadriplegia and muscle weakness. The resident's care plan specified that all surface-to-surface transfers must be performed using a total mechanical lift with the assistance of two nursing staff members. Despite this, during a bed-to-Geri-recliner transfer, one CNA attempted to transfer the resident alone, without waiting for the second CNA to assist, and did not lock the Geri-recliner or open the base of the lift as required by policy. As a result of these actions, the resident, who was dependent for mobility and transfers and had additional conditions such as colostomy, contractures, paralysis, and pressure ulcers, was observed on the floor with the transfer sling beneath him and the mechanical lift and Geri-recliner overturned. The incident led to the resident sustaining an acute displaced fracture of the left anterolateral rib, as confirmed by hospital imaging. The resident reported pain immediately following the incident and required pain management upon return to the facility. Interviews with facility staff and review of records confirmed that all CNAs had access to care instructions via facility software and had received training on the requirement for two staff members during mechanical lift transfers. Both CNAs involved in the incident acknowledged the policy and their failure to follow it, which directly resulted in the resident's fall and injury. The facility's investigation corroborated that the transfer was performed in violation of established protocols.
Failure to Prevent Accidents Due to Inadequate Supervision and Staff Training
Penalty
Summary
The facility failed to ensure adequate supervision and implementation of safety interventions to prevent accidents for two residents. In the first incident, a resident who was dependent for transfers and required the use of a mechanical lift with two staff members was transferred by a single CNA without assistance. The CNA did not lock the Geri-recliner or open the base of the lift, resulting in the resident falling to the floor and sustaining a rib fracture. Both CNAs involved had received training indicating that two staff were required for mechanical lift transfers, but the procedure was not followed, and the incident was confirmed by interviews and documentation. In the second incident, another resident was being transported back to the facility from a hospital in a wheelchair via the facility van. During transport, the wheelchair moved and tilted backward, causing the resident, still in the wheelchair, to fall onto the floor of the van. The CNAs responsible for the transport had not received formal training or competency checks for the use of the van's securement system. The DON provided only a verbal explanation of the securement process without demonstration or requiring return demonstration. The resident did not sustain injury, but the event was reported and confirmed by the resident, staff, and documentation. Both incidents involved residents with significant medical histories and physical impairments. The first resident had acute respiratory failure, lack of coordination, osteoporosis, and was dependent for transfers. The second resident had acute kidney failure, cognitive communication deficit, vascular dementia, and muscle weakness, and required a wheelchair for mobility. The deficiencies were directly related to staff not following established policies and lack of adequate training or supervision during critical procedures, resulting in preventable accidents.
Failure to Ensure Staff Competency in Resident Transportation
Penalty
Summary
The facility failed to ensure that staff responsible for transporting residents possessed and demonstrated the necessary competencies to safely carry out their duties. Specifically, the facility's policy on transportation did not address requirements or training qualifications for staff performing resident transportation. Record review and staff interviews revealed that two CNAs who transported a resident from a hospital back to the facility had not received formal training, demonstration, or competency checkoff for the operation of the facility van, its lift, or the resident securement system. Both CNAs confirmed they had not been trained in the safe use of the securement system prior to the incident. During the transport, the resident, who had severe cognitive impairment and required assistance for transfers and mobility, experienced an incident where his wheelchair turned over backwards and landed on the floor of the van. The CNAs assisted the resident, who remained in the wheelchair, back to an upright position and completed the transport. The LPN evaluated the resident upon return and found no injury or complaints of pain. The incident was reported to the resident's representative, primary healthcare provider, and the Director of Nursing, and an incident report was completed. Further interviews revealed that the Maintenance Supervisor, responsible for training staff on the van and securement system, had just started in the position and had not yet provided any training. The DON stated she had only verbally explained the securement system to the CNAs without demonstration or requiring return demonstration. Personnel files for the CNAs involved showed no documentation of training specific to the operation of the facility van or securement system. The lack of formal training and competency verification directly contributed to the unsafe transport of the resident.
Failure to Prevent Unsupervised Exit of Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment exited the facility unsupervised through the front door, which was held open by a lawn service worker. The resident, who had a BIMS score of 7 indicating severe cognitive impairment and diagnoses including heart failure and vascular dementia, was not identified as an elopement risk and had no prior history of wandering behaviors. Despite this, the resident was able to leave the building in her wheelchair without staff noticing. The incident took place when a lawn care worker, who did not speak or read English, opened and held the facility's front door while waiting to exit after completing work in the inner courtyard. The worker was unable to interpret the posted signage instructing individuals not to allow residents to exit. As a result, the resident followed the worker outside and was left unsupervised in the facility's parking lot for approximately three minutes before being found by a visitor. Staff interviews and record reviews confirmed that the resident was last seen inside the facility at 11:05 AM and was found at 11:08 AM, approximately 145 feet from the front door. The resident was assessed and found to be in no distress, and all other residents were accounted for following the incident. The facility's policy required the environment to be as free from accident hazards as possible and for residents to receive adequate supervision to prevent accidents, but these measures were not effectively implemented in this case.
Failure to Update Care Plan for New CPAP Order
Penalty
Summary
The facility failed to develop and revise a comprehensive care plan in accordance with physician orders and professional standards for one resident who required respiratory equipment. Specifically, after a new physician order was issued for an auto-adjusting CPAP machine with a pressure range of 8-18 cm H2O and modem setup, the facility did not update the resident's care plan to reflect this change. The care plan continued to reference an outdated CPAP setting of 4 cm H2O, and there was no documentation that the interdisciplinary team reviewed or implemented updated interventions related to the new therapy. Record reviews confirmed that the resident, who had a history of bipolar disorder and moderate cognitive impairment, received the new CPAP machine but the care plan was not updated accordingly. Interviews with the LPN/MDS Coordinator, DON, and Administrator all confirmed that the new physician order was not incorporated into the care plan and that the interdisciplinary team did not review or revise the plan to address the resident's updated respiratory needs.
Failure to Timely Transcribe and Provide Ordered C-Pap Equipment
Penalty
Summary
The facility failed to ensure that services were provided and documented according to professional standards for one resident who required a new Continuous Positive Airway Pressure (C-Pap) machine. A physician's order for a new C-Pap machine was issued on 1/31/25 following a sleep study, but the order was not transcribed or acted upon until nearly four months later. The facility's policy requires that physician orders be transcribed and followed as written, with clarification obtained when needed. However, the order for the new C-Pap machine was not entered, and the resident did not receive the prescribed equipment until 5/28/25. The resident involved had a history of bipolar disorder and was assessed as moderately cognitively impaired. Documentation showed that the resident was only fitted for and received the C-Pap machine after a significant delay. Interviews with the DON and Administrator confirmed that the order was known to facility leadership shortly after it was written, but authorization to obtain the equipment was not given until months later. The nurse practitioner also confirmed the importance of timely provision of the C-Pap machine as ordered by the pulmonologist.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect two residents from abuse, violating their right to be free from all forms of abuse. Resident #1 was involved in two separate incidents. In the first incident, Resident #1's roommate reported hearing Resident #1 say, 'Stop hitting me,' followed by a popping sound and a scream during care provided by CNA #1. In the second incident, Resident #1 was subjected to verbal abuse by CNA #2, who made belittling and inappropriate remarks about the resident's appearance and past experiences. These incidents were reported by Resident #1's roommate, who also provided an audio recording of the verbal abuse. Resident #2 reported being physically abused by CNA #1, who struck her on the knuckles during care when she did not release her grip on a positioner. Resident #2 recalled the incident clearly, stating that she was told to let go and was struck when she did not comply immediately. Both residents involved had cognitive impairments, with Resident #1 having severe cognitive impairment and Resident #2 having moderate cognitive impairment, as indicated by their BIMS scores. The facility's policy on preventing resident abuse was not adhered to, as evidenced by the incidents involving CNAs #1 and #2. The facility's investigations confirmed the allegations, and both CNAs were suspended and subsequently terminated. The incidents were reported to the State Agency certification division, but the report does not mention any immediate jeopardy or removal plan being submitted by the facility.
Failure to Implement ADL Care Plan for Resident
Penalty
Summary
The facility failed to implement care plan interventions for a resident requiring assistance with Activities of Daily Living (ADL) due to muscle weakness and Alzheimer's Disease. During an evening meal observation, the resident was found alone in her room with her supper tray on the over-the-bed table. The resident's soda can was unopened, and her utensils were placed out of reach, preventing her from eating and drinking independently. The resident confirmed her inability to open the can and locate her utensils, which were essential for her to feed herself. The Licensed Practical Nurse (LPN) and the Director of Nursing (DON) confirmed that the resident's care plan required staff to assist with meal setup, including opening containers and ensuring utensils were within reach. The facility's failure to adhere to the care plan interventions was acknowledged by the DON and Administrator, who confirmed that such assistance was expected as part of the resident's ADL care plan. The resident's medical history included Alzheimer's Disease, Glaucoma, Muscle Weakness, and Diabetes, which necessitated the need for assistance with ADLs.
Failure to Assist Resident with Dining Needs
Penalty
Summary
The facility failed to provide appropriate services to maintain a resident's ability to perform activities of daily living, specifically dining and eating. During an observation, it was noted that a resident was left alone in her room with her supper tray placed on an over-the-bed table. The resident's soda can was unopened, and her utensils were out of reach, preventing her from feeding herself. The resident confirmed her inability to open the soda can and locate her utensils, which hindered her ability to eat independently. This incident was observed by a Licensed Practical Nurse and the Director of Nursing, who acknowledged that the drink should have been opened and the utensils placed within reach as part of the meal set-up assistance. The resident involved in this deficiency was admitted to the facility with diagnoses including Alzheimer's Disease, Glaucoma, Muscle Weakness, and Diabetes. A review of her Quarterly Minimum Data Set indicated a Brief Interview for Mental Status score of 9, suggesting moderate cognitive impairment. The facility's policy on meal assistance clearly outlines the need to ensure that residents can reach their utensils and have their food and drink prepared for consumption, which was not adhered to in this case. The Director of Nursing and the Administrator confirmed that the assistance for eating should include opening containers and ensuring utensils are accessible during tray set-up.
Failure to Serve Palatable Meals as Per Menu
Penalty
Summary
The facility failed to provide a meal that was palatable in appearance and consistent with the posted menu for two residents. On the evening of 3/19/25, the menu listed a club sandwich, but the sandwiches served did not match the facility's recipe or the residents' expectations. Resident #4 received a slice of ham on an intact hoagie bun without vegetables, chips, or French fries, which she found difficult to eat. Similarly, Resident #3 was served a sandwich with small ham squares and mayonnaise on a hoagie bun, lacking the expected ingredients of a club sandwich. Both residents expressed dissatisfaction with the meal's appearance and composition. The facility's policy required that foods be served as planned on the menu unless there was a legitimate reason for deviation. Interviews with the Administrator and dietary staff confirmed that the posted menus should be followed and that recipes were available online. The Dietary Manager in Training was unsure of the correct ingredients for a club sandwich, indicating a lack of adherence to the facility's menu and recipe guidelines. Resident #4, with no cognitive impairment, and Resident #3, with severe cognitive impairment, both experienced meals that did not meet the facility's standards or their expectations.
Deficient Discharge Notice for Resident
Penalty
Summary
The facility failed to ensure that the written notice of discharge for a resident included all required elements for a facility-initiated discharge. The discharge letter, dated and sent by certified mail, was received by the resident's representative 12 days after it was dated. The letter did not include a discharge plan, an actual discharge date, the reason for discharge, the location to which the resident was being discharged, or the contact information for the agency responsible for protection and advocacy of individuals with a mental disorder. The resident's brother expressed concerns about the lack of communication and the insufficient notice period before the discharge. The resident, who had been diagnosed with schizophrenia and vascular dementia with behavioral disturbance, was transferred to a hospital's behavioral health unit due to inappropriate sexual behavior towards staff and residents. The transfer occurred before the 30-day notice period had elapsed, as the resident was moved to the hospital three days before the discharge date mentioned in the notice. Interviews with facility staff revealed a lack of understanding and experience in preparing discharge letters, contributing to the deficiency in the discharge process.
Failure to Notify Physician and Resident Representative After Transfer Incident
Penalty
Summary
The facility failed to notify the physician or the resident representative when a resident experienced pain in her right knee after a transfer incident, which resulted in a femoral fracture diagnosed the following day. The incident involved a resident who required a mechanical lift for transfers. During the transfer, the lift battery was dead, and while the nurse was fetching a replacement, the resident began sliding out of the chair. To prevent a fall, two CNAs manually transferred the resident, during which she yelled out in pain. Despite the resident's complaints of pain and the sitter's report, the LPN did not notify the necessary parties as per the facility's policy. The resident, admitted in 2018, had a history of hemiplegia and hemiparesis following a cerebral infarction and was cognitively intact with a BIMS score of 14. Interviews with the CNAs and the LPN revealed that the CNAs did not inform the LPN about the resident's scream during the transfer. The DON and the facility administrator confirmed that the facility's policy was not followed, as the physician, DON, and resident representative were not notified of the incident and the resident's pain complaints.
Failure to Implement Pain Management Care Plan
Penalty
Summary
The facility failed to implement care plan interventions related to pain management for a resident who yelled out in pain during a transfer. The care plan for the resident, who was at risk for pain, included documenting the type, location, and severity of pain and administering medications as ordered. However, on the day of the incident, the resident complained of right leg pain, and no pain medication was administered. The resident was later found to have a right distal femur fracture after being transferred to a hospital. Interviews with facility staff revealed that the Licensed Practical Nurse (LPN) on duty did not administer the prescribed pain medication or report the resident's pain to the oncoming nurse. The Director of Nursing (DON) and the Administrator confirmed that the care plan interventions were not followed, as the staff failed to administer pain medication and document the resident's pain. The resident had been admitted to the facility with diagnoses including age-related osteoporosis and hemiplegia following a cerebral infarction.
Failure to Ensure Safe Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to ensure a resident was free from accidents and hazards during a transfer process, which resulted in a right femur fracture for the resident. The incident involved a resident who was care planned for transfers via a mechanical lift. During the transfer, the battery of the mechanical lift was found to be dead, and while a nurse went to retrieve a new battery, the resident began sliding out of the wheelchair. In an attempt to prevent the resident from falling, two CNAs manually transferred the resident by lifting the lift pad, which was not in accordance with the facility's no-lift policy. The resident, who had a history of age-related osteoporosis and hemiplegia following a cerebral infarction, was cognitively intact at the time of the incident. The CNAs involved in the transfer did not report the resident's scream during the manual transfer, and the nurse did not investigate further or report the incident to the unit manager or DON. The facility's policy required incidents and accidents to be investigated immediately, but this was not adhered to in this case. Interviews with the staff and the resident's sitter revealed that the lift pad straps were detached from the mechanical lift, and the CNAs decided to manually transfer the resident despite the facility's no-lift policy. The DON and Administrator were not informed of the incident until after the resident was diagnosed with a femur fracture at the hospital. The facility's failure to follow proper procedures and ensure adequate supervision during the transfer process led to the resident's injury.
Failure in Pain Management for Resident Post-Transfer
Penalty
Summary
The facility failed to provide appropriate pain management for a resident who complained of pain following a manual transfer from her wheelchair to the bed. The incident occurred when the lift battery was dead, and the CNAs manually transferred the resident, resulting in her screaming out in pain. Despite the resident's complaint of pain, the LPN on duty did not administer any pain medication on the day of the incident, which was against the facility's pain management policy. The resident, who was cognitively intact with a BIMS score of 14, had a medical history including age-related osteoporosis and hemiplegia following a cerebral infarction. The following day, the resident received a routine Duragesic patch for pain, but no immediate pain relief was provided after the incident. The facility's investigation confirmed that the staff failed to follow the pain management policy, as acknowledged by both the DON and the Administrator.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a kitchen inspection. The inspection revealed multiple instances of improper food storage and labeling, including unlabeled food items, exposed food, and overly ripe produce with biological growth. Specifically, in Refrigerator #1, there were overly ripe green tomatoes, cucumbers, and bell peppers with bio-growth, and several food items such as sweet potatoes, tomato soup, scrambled eggs, gravy, and bacon were found without labels and improperly covered. Additionally, there were trays of juices and thickened beverages without labels, and opened cartons of thickened juices lacked proper labeling of open dates. Unlabeled condiment cups and a smoothie bottle were also found, with the Dietary Manager unable to identify the owner of the smoothie. Further inspection of the pantry revealed a scoop improperly stored inside a flour bin, open containers of garlic seasoning, and several opened containers of sauces that required refrigeration according to the manufacturer's label. The Dietary Manager confirmed the presence of overly ripe produce, exposed foods, and the failure to refrigerate perishable items, attributing the oversight to the weekend cook's failure to check for spoiled and expired foods. The Administrator was informed of these findings and stated an expectation for kitchen staff to monitor food storage and labeling daily to ensure food safety.
Failure to Assess and Evaluate Use of Physical Restraint
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints by not completing an assessment and evaluation for an upper body harness vest and not ensuring it was the least restrictive device. The facility's policy mandates that restraints should only be used for the safety and well-being of residents after other alternatives have been tried unsuccessfully and with informed consent. However, for the resident in question, the necessary assessment and evaluation were not conducted, and the restraint decision form was not completed prior to the application of the restraint. The resident, who was admitted with a diagnosis of metabolic encephalopathy and had a moderately impaired cognitive status, was observed using a wheelchair harness vest. The vest was brought in by a family member and used without a proper assessment. The Director of Nursing admitted that the assessment and evaluation were missed, and the staff had not received in-service training for the device. The Physical Therapist confirmed that the resident had not been recently evaluated for posture and would not recommend restraints without a thorough assessment.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to ensure proper storage of respiratory equipment for a resident, as evidenced by observations of undated and unbagged oxygen tubing. The facility's policy, dated April 2007, required that all respiratory tubing be replaced weekly, dated, and stored in a dated plastic bag when not in use to decrease the risk of exposure to infectious diseases and contaminants. However, during multiple observations, the oxygen tubing on the resident's wheelchair was found to be undated and not stored in a plastic bag, despite the resident using a bedside concentrator while in bed. Interviews with facility staff, including LPNs and the Director of Nursing, confirmed the policy requirements for changing and storing respiratory tubing. LPN #4 admitted to never having seen the required storage bags, and LPN #1 reiterated the policy's intent to reduce exposure risks. The Director of Nursing stated that it was the cart nurse's responsibility to manage the tubing, with changes typically occurring on the Sunday night to Monday morning shift. The resident involved had a diagnosis of Metabolic Encephalopathy and had an active order for oxygen use as needed for shortness of breath.
Deficiency in Restraint Management and QAPI Committee
Penalty
Summary
The facility failed to sustain an effective Quality Assurance and Performance Improvement (QAPI) committee, as evidenced by a re-cited deficiency originally identified in July 2023 during an annual recertification survey. The deficiency involved the facility's failure to ensure a resident was free from physical restraints. Specifically, the facility did not assess for a least restrictive restraint for one resident and failed to obtain a physician order for the use of a restraint for one of the three residents reviewed for restraints.
Resident Left Unfed Due to Staff Meeting Interruption
Penalty
Summary
The facility failed to accommodate the needs of a resident who was dependent on staff for eating, resulting in the resident being left unassisted and unfed during a meal. The incident involved a resident with quadriplegia and complete muscle weakness, who was cognitively intact. During a meal, a CNA was feeding the resident when an LPN interrupted and demanded the CNA attend a meeting, leaving the resident with a meal tray in front of her. The resident expressed feeling disrespected and hungry as she had to wait for the CNA to return, and her food had become cold. The CNA confirmed that she was feeding the resident when the LPN insisted she stop and attend a meeting. Despite initially continuing to feed the resident, the CNA eventually complied with the LPN's demand, leaving the resident unattended for about twenty to thirty minutes. Upon returning, the CNA found the resident's food cold and took steps to provide warm food, further delaying the meal. The Director of Nursing acknowledged that the resident should have been fed first and that the nurse's actions were inappropriate.
Failure to Implement Care Plan Leads to Resident Accessing Medication Cart
Penalty
Summary
The facility failed to implement a care plan to prevent a resident's access to a medication cart, resulting in a resident opening an unlocked medication cart and consuming Lactulose liquid. This incident involved a resident with moderate cognitive impairment and impaired communication ability, who was known to be at risk for self-harm by removing items from the medication cart and placing them in their mouth. The care plan for this resident included interventions such as keeping all medication carts locked and free of harmful items. On the day of the incident, a Licensed Practical Nurse (LPN) assigned to the resident's care observed the resident seated next to the medication cart with an open drawer and a bottle of Lactulose in hand. The LPN was not aware of the care plan interventions related to the resident's cognitive impairment and risk for self-harm. The Director of Nurses (DON) and the facility Administrator were aware of the resident's history of rummaging and drinking inappropriate substances, and the care plan addressed these risk factors. The incident report indicated that the resident consumed approximately 60 cc of Lactulose, and immediate actions were taken, including contacting Poison Control and a Nurse Practitioner. Interviews with facility staff revealed that the care plan was not followed, and the medication cart was left unlocked and unattended, allowing the resident to access the medication. The facility's policy required all employees to follow the written care plan to meet the residents' needs, which was not adhered to in this case.
Removal Plan
- The care plan is being followed for Resident #1.
- Resident #1 is having one on one supervision at all times.
- A nurse was assigned to the dementia unit each shift for increased supervision for cognitively impaired residents who reside there.
- Resident #1 has been assessed for injuries with no adverse effects noted.
- Resident Representative attempted to be notified by phone at time of incident with no success. Several phone attempts were followed up by facility with no success. Letter mailed to resident representative for notification of incident.
- The Director of Nursing (DON), Staff Development, Administrator and Registered Nurse (RN) Supervisors provided education to staff whom are directly involved in passing medication and responsible for medication carts.
- An emphasis was placed on ensuring all carts in the facility are always locked when not in attendance.
- In-service also including following the care plan for Resident #1.
- In-service is ongoing and continues until all nurses are educated prior to working their shift.
- There is a designated nurse assigned to the dementia unit each shift to increase supervision of cognitively impaired residents.
- The Director of Nursing (DON), Staff Development, Administrator and Registered Nurse (RN) Supervisors provided education on the one on one supervision on Resident #1.
- This in-service is ongoing and will continue until all nursing staff have been in-serviced prior to working their scheduled shift.
- The Minimum Data Set (MDS) nurse updated the care plan and Kardex to reflect the need for one on one supervision.
- Behavior monitoring has been ongoing with this resident but was updated to include the behavior of rummaging.
- The DON or Staff Development Nurse has assigned a staff member each shift to make rounds every 30 minutes to check that all carts in the facility are locked.
- The Director of Nursing, Staff Development Nurse or Registered Nurse Supervisor are assigned to audit the one on one supervision sheets on a daily basis for compliance with one on one supervision of Resident #1.
- AD HOC Quality Assurance (QA) meeting held to review plans for removal of Immediate Jeopardy (IJ) tag.
Resident Accesses Unlocked Medication Cart
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards, as evidenced by an incident involving a resident who accessed an unlocked and unattended medication cart. The resident, who had a history of rummaging and consuming inappropriate substances, managed to open the cart and ingest a bottle of Lactulose. This incident was classified as an Immediate Jeopardy and Substandard Quality of Care, indicating a serious breach in safety protocols that could lead to significant harm. The resident involved in the incident had been admitted to the facility with diagnoses including Dementia with Behavioral Disturbance, Impulse Disorder, and a history of Traumatic Brain Injury. The resident was known to have cognitive limitations, wandering behaviors, and a tendency to consume liquids not intended for ingestion. On the day of the incident, a Licensed Practical Nurse (LPN) inadvertently left the medication cart unlocked while stepping away, allowing the resident to access and drink from a bottle of Lactulose. Interviews with facility staff, including the LPN involved, the Director of Nurses (DON), and the Administrator, revealed awareness of the resident's behaviors and the necessity for secure storage of medications. Despite this knowledge, the failure to ensure the medication cart was locked resulted in the resident's access to the medication. The incident highlighted the need for strict adherence to safety protocols to prevent similar occurrences in the future.
Removal Plan
- The care plan is being followed for Resident #1.
- Resident #1 is having one on one supervision at all times.
- A nurse was assigned to the dementia unit each shift for increased supervision for cognitively impaired residents who reside there.
- Resident #1 has been assessed for injuries with no adverse effects noted.
- Resident Representative attempted to be notified by phone at time of incident with no success. Several phone attempts were followed up by facility with no success. Letter mailed to resident representative for notification of incident.
- The Director of Nursing (DON), Staff Development, Administrator and Registered Nurse (RN) Supervisors provided education to staff whom are directly involved in passing medication and responsible for medication carts.
- An emphasis was placed on ensuring all carts in the facility are always locked when not in attendance.
- In-service also including following the care plan for Resident #1.
- In-service is ongoing and continues until all nurses are educated prior to working their shift.
- There is a designated nurse assigned to the dementia unit each shift to increase supervision of cognitively impaired residents.
- The Director of Nursing (DON), Staff Development, Administrator and Registered Nurse (RN) Supervisors provided education on the one on one supervision on Resident #1.
- This in-service is ongoing and will continue until all nursing staff have been in-serviced prior to working their scheduled shift.
- The Minimum Data Set (MDS) nurse updated the care plan and Kardex to reflect the need for one on one supervision.
- Behavior monitoring has been ongoing with this resident but was updated to include the behavior of rummaging.
- The DON or Staff Development Nurse has assigned a staff member each shift to make rounds every 30 minutes to check that all carts in the facility are locked.
- The Director of Nursing, Staff Development Nurse or Registered Nurse Supervisor are assigned to audit the one on one supervision sheets on a daily basis for compliance with one on one supervision of Resident #1.
- AD HOC Quality Assurance (QA) meeting held to review plans for removal of Immediate Jeopardy (IJ) tag.
Failure to Notify Resident Representative of Change in Condition
Penalty
Summary
The facility failed to notify the resident representative (RR) of a severely cognitively impaired resident about a change in the resident's condition. The deficiency involved a failure to communicate the presence of scratches on the resident's chest, which were noted during a body audit conducted by the Director of Nursing (DON) on a specific date. Despite the facility's policy requiring notification of family or resident representatives about changes in a resident's condition, the DON forgot to inform the RR about the scratches. The resident, who had been admitted to the facility with diagnoses including Chronic Leukemia, Type 2 Diabetes, Chronic Kidney Disease, and Unspecified Dementia, had a Brief Interview for Mental Status (BIMS) score indicating severe cognitive impairment. The RR discovered the scratches during a visit and subsequently filed a grievance due to the lack of notification. The grievance led to an acknowledgment from the DON that the scratches were noted but not communicated to the RR, which was a deviation from the facility's policy.
Failure to Report Resident-to-Resident Non-Consensual Contact
Penalty
Summary
The facility failed to report an allegation of resident-to-resident non-consensual sexual contact to the State Agency within the required timeframe. The incident involved two residents with dementia, where one resident was observed by an LPN to have inappropriately touched another resident on two separate occasions. The LPN documented these observations in the residents' behavioral progress notes and informed the RN Supervisor. However, the RN Supervisor stated that she was only informed of verbal remarks and not the physical contact, which she would have reported to the DON if known. The Social Service Director became aware of the incidents during a Minimum Data Set assessment and reported them to the Interdisciplinary Team, including the Administrator and DON, three days after the incidents occurred. Despite this, the DON did not report the allegations to the State Agency or any other agency. The Administrator confirmed that no report was submitted and mentioned that they consult with corporate on potentially reportable incidents. The resident involved in the inappropriate behavior had a history of schizophrenia, vascular dementia with behavioral disturbances, and moderate cognitive impairment.
Failure to Secure Hazardous Chemicals and Supervise Resident
Penalty
Summary
The facility failed to ensure the environment was free from accident hazards and that residents received adequate supervision to prevent a resident from ingesting a cleaning solution. The incident involved a resident with wandering behaviors who retrieved a cleaning solution from an unsecured housekeeping cart. The facility's policy required hazardous chemicals to be locked when not in use and under direct control of facility personnel while in common areas, but this was not followed in this case. On the day of the incident, a housekeeper left her cleaning cart unlocked and unattended while cleaning a bathroom. The resident, known for wandering and taking unsecured items, accessed the cart and consumed a small amount of the cleaning solution. The Director of Nurses confirmed that the resident's nurse witnessed the ingestion and took immediate action by contacting the Nurse Practitioner and poison control for further instructions. Interviews with the housekeeping staff revealed that they were aware of the policy to keep carts locked and aligned with the room they were cleaning but failed to adhere to it. The resident involved had a history of dementia with behavioral disturbances, impulse disorder, and psychotic disorder with hallucinations, making him particularly vulnerable to such hazards. The facility's failure to secure hazardous chemicals and supervise the resident adequately led to this preventable incident.
Failure to Timely Manage and Treat Pain Complaints
Penalty
Summary
The facility failed to timely manage and treat complaints of pain for two residents when there was no licensed nurse available on their unit from approximately 7:00 PM on 3/22/24 until approximately 1:47 AM on 3/23/24. Resident #2 reported severe pain rated nine on a 0-10 pain scale to a CNA, who informed her that there was no nurse available to administer medication. Resident #2 had a physician order for Norco to be given every six hours as needed for pain, but she did not receive her medication until later that night, causing her to stay awake due to the pain. Resident #2 was cognitively intact with a BIMS score of 15 and had diagnoses including Type 2 diabetes and Peripheral autonomic neuropathy. Resident #4, who had undergone surgery and was experiencing surgical-related pain, also reported pain to a CNA on the evening of 3/22/24. The CNA informed Resident #4 that there was no nurse available to administer pain medication. Resident #4 rated her pain as 5 to 6 on a 0-10 pain scale. She had physician orders for multiple pain medications, including Acetaminophen, Hydrocodone-Acetaminophen, and Tramadol, to be given every six hours as needed. Resident #4 had a BIMS score of 12, indicating moderate cognitive impairment, and had diagnoses including Encounter for orthopedic aftercare following surgical amputation and Peripheral vascular disease. Interviews with staff revealed that the RN Supervisor did not visit the 500 Hall during her shift, and the LPN assigned to the 600 and 800 Halls did not attend to the 500 Hall residents. The LPN assumed that a Float Nurse would cover the 500 Hall, but the Float Nurse did not show up, and the On-Call Nurse did not respond to calls. The Director of Nurses confirmed that there was a break in staff communication, leading to the failure to monitor and administer medications to the residents on the 500 Hall for approximately six hours and 45 minutes. The Administrator was unaware of the staffing issue until inquiries were made by the State Agency on 4/01/24.
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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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