Grand Trace Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Natchez, Mississippi.
- Location
- 555 John R. Junkin Drive, Natchez, Mississippi 39120
- CMS Provider Number
- 255173
- Inspections on file
- 19
- Latest survey
- April 1, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Grand Trace Health And Rehabilitation during CMS and state inspections, most recent first.
A resident with multiple unstageable pressure ulcers of both heels and the right ankle had physician orders and facility policies directing wound cleansing to minimize contamination and infection risk. During observed wound care, an RN repeatedly wiped over the open ankle and heel wounds using the same surface of gauze moistened with wound cleanser and did not wear a gown while treating one ankle, contrary to the facility’s clean dressing change and pressure injury management policies. The DON stated nurses were expected to follow infection control standards, and the Staff Development Coordinator noted the RN had just completed a wound care competency that required proper cleansing technique. In interview, the RN admitted wiping over the open wounds multiple times with the same side of the gauze, was unaware of the facility’s wound care protocols, and reported that no protocol had been provided.
A resident with moderate cognitive impairment, a history of stroke, dysphagia, aphasia, and multiple pressure ulcers required extensive assistance with toileting and perineal care. During observed incontinence care, a CNA used premoistened wipes to clean the resident’s genital and perineal areas but repeatedly wiped back and forth with visibly soiled surfaces instead of using a clean surface for each front-to-back stroke, and then used the same wipes on the rectal area and scrotum. This technique did not follow the facility’s incontinence care policy or the CNA’s documented competency instructions, which required cleaning the penis and scrotum with clean cloths and cleaning the anal area front to back without contaminating the perineal area. The DON and Administrator both stated they expected nursing staff to supervise care and ensure incontinence care was provided in a manner that would prevent infection, and the DON acknowledged that wiping back and forth with soiled wipes could lead to UTI.
A resident with multiple unstageable pressure ulcers and moderate cognitive impairment had an active order for Enhanced Barrier Precautions (EBP) related to wounds. Facility policies required wound care to be provided in a manner that prevents infection and cross-contamination, and EBP signage with required PPE was posted on the resident’s door. Despite this, an RN performed wound care to open ankle and heel wounds without donning a gown, even though PPE was available and the RN had recently completed wound care competency training. Leadership, including the DON and Staff Development Coordinator, confirmed expectations that staff follow current infection control standards and use appropriate PPE for residents on EBP.
A cognitively intact resident with a history of major depressive disorder was denied her right to receive visitors of her choosing when her regular visitor and friend was told by staff to leave the facility and was not allowed to stay or have the resident notified of his presence. The facility’s own Resident Rights policy states that residents may receive visitors of their choosing at times of their choosing, yet the IDON acknowledged she directed the friend to leave and confirmed staff did not inform the resident of the attempted visit, while the Administrator later stated he was unaware of the incident.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
The facility did not provide RN coverage for at least eight hours a day, seven days a week, as required. For eight days, no RN was present for a full 24-hour period. An LPN and the DON were counted toward RN staffing, with the DON often acting as both Charge Nurse and DON. The Nurse Consultant and Interim Administrator were unaware of the actual staffing practices, and the facility's census exceeded sixty during the period in question.
A resident with functional quadriplegia was repeatedly observed without an accessible call light, as the available push and touch button types could not be used due to paralysis. Despite being alert and oriented, the resident reported long wait times for assistance and informed multiple staff members of his inability to use the provided call lights. Staff interviews confirmed the call light was often out of reach, and no alternative system, such as a blow-call light, was provided.
A resident requiring total assistance with ADLs, including bathing and grooming, did not receive regular bed baths or shaving, as observed by surveyors and reported by the resident. The resident remained in bed with visible chin hair and a persistent urine odor in the room, and there was no documentation of care refusals. The facility's policy required staff to provide necessary ADL support, but this was not consistently done.
A facility failed to provide adequate nursing staff, resulting in high resident-to-CNA ratios and delays in essential care such as bathing, changing, and repositioning. A resident dependent on staff for personal care was observed unshaven and in a room with a strong urine odor, reporting missed showers. Staff interviews confirmed frequent staffing shortages, with CNAs and LPNs working extra shifts and residents experiencing extended wait times for care.
Improper Wound Cleansing Technique for Pressure Ulcers
Penalty
Summary
Surveyors identified a deficiency in the facility’s provision of pressure ulcer care and infection prevention for one resident with multiple pressure injuries. Facility policies on Pressure Injury Prevention and Management and Clean Dressing Change required cleansing wounds in a manner that decreases infection risk, including cleaning outward from the center of the wound and avoiding contamination of other skin surfaces or wound surfaces. The resident, admitted with diagnoses including aphasia, dysphagia, cerebral infarction, and unstageable pressure ulcers of both heels and the right ankle, had physician orders to cleanse the right lateral foot, right heel, and left heel pressure ulcers with wound cleaner, pat dry, and apply specified dressings once daily and as needed. The March Treatment Administration Record showed that a registered nurse documented providing these ordered treatments on the date of the survey observation. During direct observation of wound care, the RN cleansed the open pressure areas on the resident’s right ankle and heel by repeatedly wiping from above the open wound to below it using gauze moistened with wound cleanser, then using a new piece of gauze but again wiping multiple times over the open area with the same surface of the gauze. The RN then performed similar wound care on the left ankle without wearing a gown and again wiped over the open wound multiple times with the same surface of the wet gauze. This technique did not follow the facility’s written procedure to cleanse wounds in a way that avoids contaminating other skin or wound surfaces. The DON stated she expected nurses to follow current infection control standards, including cleaning away from open wounds and using clean surfaces of gauze for each contact. The Staff Development Coordinator reported that the RN had completed a wound care competency checkoff the same day, which included cleansing the wound without contaminating other surfaces. In an interview, the RN acknowledged wiping over the open wound multiple times with the same side of the gauze to remove discharge or slough, stated she was not aware of the facility’s wound care protocols, and said the facility did not provide a protocol to follow.
Improper Infection Control During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper infection control techniques during incontinence care for one sampled resident. Facility policy on incontinence care required that residents who are incontinent of bowel or bladder receive appropriate treatment to prevent infections, and the CNA competency checklist specified cleaning the penis in a circular motion from the tip using downward strokes, then cleaning the scrotal area with a fresh washcloth, and cleaning the anal area front to back without contaminating the perineal area. During an observed episode of incontinence care, CNA #1 used three premoistened disposable wipes to clean the resident’s penis and anterior perineal area front to back, resulting in visible soiling of the wipes, and then continued to wipe back and forth three more times without changing sides of the wipes or using new wipes. CNA #1 then discarded those wipes, obtained three new wipes, cleaned the resident’s rectal area back and forth three times, and then wiped the scrotum with the same soiled wipes. The resident involved had been admitted with diagnoses including aphasia, dysphagia, cerebral infarction, and unstageable pressure ulcers of both heels, and had a BIMS score indicating moderate cognitive impairment and four pressure ulcers at the time of a recent MDS assessment. The Kardex indicated the resident required extensive assistance with bed mobility and toileting, with staff responsible for cleaning the perineal area with each incontinence episode. Interviews revealed that CNA #1 did not verbally confirm awareness of the correct procedure or facility protocol for incontinence care when questioned. The DON stated she expected nurses to supervise resident care and CNAs to provide incontinence care in a manner that would prevent infection, including wiping only front to back one time with a clean surface of the cloth and ensuring each wipe was done with a clean surface, and confirmed that wiping back and forth multiple times with a soiled surface could lead to urinary tract infection. The Staff Development Coordinator reported that CNA #1 had previously completed a competency checkoff on incontinence care procedures, and the Administrator stated he expected nurses to supervise care and that incontinent residents would receive care in a manner to prevent infections.
Failure to Use Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement its infection prevention and control program by not using Enhanced Barrier Precautions (EBP) during wound care for a resident with multiple pressure injuries. Facility policies titled "Pressure Injury Prevention and Management" and "Clean Dressing Change," both revised on 11/07/25, stated the facility’s commitment to preventing pressure injuries, providing treatment and services to heal pressure ulcers/injuries, and decreasing the potential for infection and cross-contamination during wound care. The resident’s care profile contained an order dated 1/20/26 for EBP related to wounds. Despite this, on 3/31/26 at 12:40 PM, observation showed that an RN performed wound care on the resident’s open pressure sore on the right ankle and heel and a pressure area on the left ankle without donning a gown, contrary to EBP requirements and facility policy. Interviews further clarified the circumstances leading to the deficiency. The DON stated she expected nurses to provide all wound care according to current infection control standards and confirmed that the facility had an ample supply of PPE and expected staff to use appropriate PPE for residents on EBP. The Staff Development Coordinator reported that she provided monthly and as-needed in-service training, including orientation training with hand hygiene and PPE competency checkoffs, and that the RN involved had completed a wound care competency checkoff on 3/31/26. The RN acknowledged that the resident had pressure ulcers on both outer ankles, that EBP were in place for direct contact care, that signage on the resident’s door listed and depicted required PPE and interactions requiring PPE, and that she did not wear a gown during the wound care. Record review showed the resident was admitted on 8/05/25 with diagnoses including aphasia, dysphagia, cerebral infarction, and multiple unstageable pressure ulcers of both heels and the right ankle, and a Significant Change MDS dated 1/16/26 documented four pressure ulcers and a BIMS score of 9, indicating moderate cognitive impairment.
Failure to Honor Resident’s Right to Receive Chosen Visitors
Penalty
Summary
Surveyors identified a failure to honor a resident’s right to receive visitors of her choosing. The facility’s Resident Rights policy, revised 11/14/25, states that residents have the right to a dignified existence, self-determination, communication, and access to persons and services inside and outside the facility, including the right to receive visitors of their choosing at times of their choosing, subject only to the resident’s right to deny visitation and not infringing on other residents’ rights. Resident #1, admitted on 11/2/22 with diagnoses including Major Depressive Disorder, had a BIMS score of 15 on the 12/31/25 MDS, indicating she was cognitively intact. She reported that on the afternoon of 1/11/26 she was aware that her friend had been turned away by staff and was not allowed to visit her. In a telephone interview, the complainant, identified as Resident #1’s friend who had been visiting her several times each week without prior concern, stated that one afternoon in January 2026, between lunch and dinner, staff told him to leave the facility and refused to allow him to stay or to notify the resident that he was there. Resident #1 expressed that she hoped to see her friend again and stated that they had not done anything wrong and that they were both adults. The Interim DON confirmed that she was aware residents have the right to visitors of their choice and acknowledged that she was the one who asked the friend to leave the premises and that staff did not notify Resident #1 that she had a visitor. The Administrator reported he was not aware of this situation but affirmed that residents have the right to receive visitors of their choosing and that, if safety concerns exist, interventions such as supervision or designated visit locations could be used; however, no such measures were implemented in this case, and the visit was instead prohibited without informing the resident.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential information and proper record-keeping were not consistently followed. No additional details about specific residents, their medical history, or the exact circumstances of the deficiency are provided in the report.
Failure to Ensure Required RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a Registered Nurse (RN) for at least eight hours a day, seven days a week, as required by regulations. Record review showed that for eight out of nineteen days reviewed, there was no documented RN coverage for a full 24-hour period. Interviews with staff revealed confusion regarding staffing requirements, with the DON being counted as both the RN and Charge Nurse, and an LPN being included on the staffing grid. The DON was the only RN present Monday through Friday, and another RN only occasionally served as Charge Nurse. The Nurse Consultant was unaware that the DON was being counted as Charge Nurse and believed that the DON and Staff Development Nurse could be counted toward RN coverage, regardless of the facility's census, which was confirmed to be over sixty during the days in question. The Interim Administrator, who had recently started at the facility, stated that he expected compliance with federal staffing regulations and the facility's own staffing assessment. Facility documentation indicated that staffing was based on census, acuity, and resident needs, with the facility assessment listing one RN DON among other nursing staff. However, the actual staffing practices did not ensure the required RN coverage, leading to the deficiency.
Failure to Provide Accessible Call Light for Resident with Quadriplegia
Penalty
Summary
The facility failed to ensure a resident's right to dignity and communication by not providing an accessible call light for a resident with functional quadriplegia. Multiple observations over several days showed the resident in bed without a call light within reach, and the available call lights (push button and touch button types) were not usable by the resident due to his paralysis. The resident repeatedly reported to staff that he could not use the provided call lights and experienced long wait times for assistance. Staff interviews confirmed that the call light was often found on the floor or out of reach, and that staff were unaware of alternative call light options suitable for the resident's needs. The resident was admitted with a diagnosis of functional quadriplegia and was alert and oriented, with documented contractures and paralysis. Despite this, staff did not assess or provide a call light system that accommodated his physical limitations. The resident stated he had previously used a blow-call light at other facilities, but this was not made available. Key staff, including CNAs, LPNs, and social services, were either unaware of the resident's inability to use the standard call lights or had not taken steps to address the issue, resulting in the resident being dependent on staff checks and occasional assistance from his roommate.
Failure to Provide Necessary ADL Assistance and Personal Hygiene
Penalty
Summary
A resident with diagnoses of muscle weakness, reduced mobility, and lack of coordination, who was assessed as requiring total assistance for bathing and showering, did not receive necessary services to maintain good grooming and personal and oral care. Observations over several days revealed the resident remained in bed with visible chin hair and reported not receiving regular bed baths or showers as previously provided. The resident expressed a desire to have her chin hair shaved and noted that no staff had asked about bathing or showering during the week. A strong and then faint odor of urine was noted in the resident's room on multiple occasions. Review of the resident's care plan indicated a need for substantial to maximal assistance with activities of daily living (ADLs), but there was no documentation of refusals of care. The facility's policy required encouragement of resident participation in ADLs and provision of assistance as necessary, but interviews and observations confirmed that the resident did not receive adequate support for personal hygiene and grooming during the period reviewed. The Corporate Nurse acknowledged awareness of these care concerns.
Insufficient Nursing Staff Resulting in Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple days with inadequate CNA coverage for a census of 67 to 69 residents. Staffing schedules and grids revealed that on several occasions, only two or three CNAs were assigned per shift, resulting in high resident-to-staff ratios. Interviews with CNAs and LPNs confirmed that low staffing levels led to delays in providing essential care, such as changing, repositioning, and bathing residents. Staff reported working extra hours and shifts, with some staff members covering both day and night shifts due to shortages. One resident, who was cognitively intact and dependent on staff for bathing and showers, was observed lying in bed with visible chin hair and a strong odor of urine in the room. The resident stated she had not received a shower since the previous Thursday and used to receive bed baths three times per week. Multiple CNAs reported that when staffing was low, residents often had to wait longer than two hours to be changed or repositioned, and scheduled showers were sometimes missed due to the lack of a designated shower aide. Interviews with staff further revealed that the facility's staffing plan was not consistently followed, with frequent call-ins and reliance on staff from other roles, such as medical records, to cover nursing duties. The DON and staff developer were responsible for creating the nurse and CNA schedules, respectively, but ongoing shortages resulted in staff being called in for extra shifts and residents experiencing delays in care. Residents and staff both reported dissatisfaction with the timeliness and adequacy of care provided during periods of low staffing.
Latest citations in Mississippi
A resident with advanced dementia and severe cognitive impairment sustained a bruised left eye and facial bruising after being struck by a CNA. The CNA initially claimed the injury occurred accidentally while pushing the resident to a dining table and denied hitting the resident, but an LPN and another CNA reported that the resident stated she had hit the CNA and was hit back in the eye, demonstrating a slapping motion. Nursing documentation described left orbital ecchymosis, bruising along the bridge of the nose and cheek, tenderness, minimal edema, and the resident’s complaint of soreness, confirming a significant injury resulting from the physical abuse.
The facility failed to protect residents’ right to a dignified and comfortable environment when it did not effectively manage one cognitively impaired resident’s ongoing nighttime yelling, which repeatedly disrupted the sleep of two cognitively intact residents. Staff, including a CNA, the DON, and the Administrator, were aware that this resident, diagnosed with dementia and psychosis, frequently yelled and screamed at night while often sleeping during the day. Progress notes documented nighttime hollering, and interviews confirmed that the disruptive behavior persisted over time, interfering with other residents’ ability to rest.
Surveyors found that the facility failed to protect two residents’ rights to dignity and privacy during routine care. One resident, with moderate cognitive impairment and dependent for toilet hygiene, was observed receiving incontinence care while uncovered, with the room door open and the privacy curtain only partially drawn, allowing visibility into the hallway despite facility policy requiring full privacy. Another resident, dependent for eating and with hemiplegia after a stroke, was assisted with lunch by a CNA who stood over the resident instead of sitting at eye level as required by the facility’s feeding skills checklist. Staff interviews, including with CNAs, an LPN, the DON, and the Administrator, confirmed that existing policies and in-service training directed staff to provide privacy during incontinence care and to sit beside residents when assisting with meals to ensure dignified care.
A resident with epilepsy, skin infection, an upper arm wound, gastrostomy status, and moderate cognitive impairment was observed twice resting in bed with a lunch tray while the call light was not within reach—once on the floor under the bed and once hanging behind the mattress, out of sight. The resident reported being able to use the call light but not knowing where it was. Staff, including CNAs, an LPN, the DON, and the Administrator, stated that call lights are expected to be left within residents’ reach and that training and competencies address this requirement, but there was no specific written policy on call light placement.
A resident with moderate cognitive impairment, dependent for toilet hygiene and with multiple medical conditions, was observed receiving incontinent care in which a CNA removed a urine-soaked brief, changed the bed sheet, and applied a clean brief without performing any required perineal cleansing of the front or back. Facility policy and the peri-care skills checklist specified that male residents must have the perineal area, including the penis, scrotum, and inner thighs, washed, rinsed, and dried during incontinent care. The CNA later acknowledged having been trained and competency-checked on this procedure and knowing cleansing was required. Other staff, including a CNA supervisor, an LPN, the DON, and the Administrator, confirmed that proper incontinent care includes full perineal cleansing in addition to brief changes, establishing that the observed omission did not follow facility policy or professional standards intended to prevent UTIs.
Surveyors found that staff failed to follow infection control practices during PEG tube and wound care. Two residents with PEG tubes had sites with visible brown, crusted or yellowish drainage that had not been cleaned for several days, despite physician orders for daily cleansing and, when indicated, dressings. In another case, a CNA provided peri-care for stool and then assisted with a stage IV sacral pressure ulcer dressing change without changing gloves or performing hand hygiene, contrary to facility policy and staff expectations for aseptic technique.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment when a resident’s room contained odorous soiled linens left on the floor and later placed on furniture with clean clothing, and the bed was made with torn linens exposing the mattress. Other residents reported that housekeeping did not clean under beds, and multiple large dead roaches were repeatedly observed under several beds, with one resident stating he often disposed of dead roaches himself. Residents also reported refusing to use the north shower room due to dirty clothing, feces, and residue on shower chairs and floors; an observation confirmed the presence of soiled clothing, a soiled brief, and unidentified substances on the shower chair and floor, despite staff acknowledging that CNAs were expected to clean and sanitize the shower room after each use.
The facility failed to maintain an effective pest control program, as evidenced by repeated observations of roaches and other insects in multiple resident rooms and common areas. Surveyors found gnats and dead roaches under beds, while several residents reported seeing roaches on ceilings, walls, and floors, including roaches falling onto them at night and having to remove dead roaches themselves. A family member reported bringing her own roach spray due to concerns about roaches in a loved one’s room. During a Resident Council meeting, roaches were seen crawling across the floor, and residents stated that roaches were commonly observed throughout the building. Although the contracted pest control provider reported monthly service focused mainly on entry points and exterior areas and facility staff described processes for reporting pests, the persistent roach activity showed the program was not effectively preventing or controlling pests.
A resident with multiple chronic conditions, who relied on phone contact with a seriously ill significant other, lost access to private communication after her personal cell phone was broken and sent out for repair. Facility policy guarantees residents access to a telephone and private communication, but there was no cordless phone available on the relevant hall, and staff, including the DON, SSD, and Administrator, confirmed there was no convenient method for residents on that hall to make private calls without arranging to use a staff office. This resulted in the resident having no readily available, private telephone option.
A resident with heart failure, chronic kidney disease, hypertension, moderate cognitive impairment, and total dependence on staff for personal and toilet hygiene reported difficulty obtaining assistance with ADLs. Observation revealed the resident had ten long, dirty fingernails extending several millimeters beyond the fingertips with black material underneath, and the resident stated they needed cleaning and cutting. An LPN confirmed the nails were too long and dirty, acknowledged that nursing staff were responsible for daily and weekly fingernail checks and for providing fingernail care as part of ADLs, and noted that such nails could cause skin damage or scratches. The DON and Administrator both confirmed that personal hygiene and grooming are part of ADLs and are expected to be provided for all residents dependent on staff.
Failure to Protect Cognitively Impaired Resident From Physical Abuse by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse, resulting in the resident being struck in the eye by a CNA. Facility records show that a CNA reported to an LPN that the resident had a bruised left eye and initially stated the injury may have occurred while pushing the resident to the dining table due to the resident’s short, stooped posture. The CNA also reported that the resident used a racial slur toward her and that she verbally responded but denied striking the resident. However, subsequent interviews and the facility’s investigation determined that the resident’s injury was not caused by accidental contact with the dining table. Interviews with staff revealed conflicting accounts that led to the conclusion that the resident had been hit. An LPN stated that the resident reported being hit in the eye by the CNA and that another CNA heard a commotion and later observed bruising to the resident’s left eye. When this second CNA asked what happened, the resident reported that she hit the CNA and was hit back in the eye, while making a motion consistent with a slap. The LPN confirmed that the resident gave a similar account to her, indicating that the CNA had physically struck the resident. The resident involved was admitted to the Memory Care Unit with diagnoses including Alzheimer’s disease, cognitive communication deficit, and unspecified dementia with behavioral disturbance, and had a BIMS score of 5 indicating severe cognitive impairment. A nursing progress note documented an acute follow-up assessment of left orbital ecchymosis, describing a dark red circular bruise to the left eye region, dark purple bruising along the lateral bridge of the nose extending to the superior left cheek, tenderness on palpation, minimal edema, and the resident’s complaint that the area was sore. Due to advanced Alzheimer’s disease, the resident was unable to reliably express additional symptoms, but the documented physical findings supported that the resident sustained a significant injury to the eye area as a result of being struck by the CNA.
Failure to Protect Residents’ Right to Rest Due to Unmanaged Nighttime Yelling
Penalty
Summary
The deficiency involves the facility’s failure to ensure a dignified and comfortable environment by not effectively addressing ongoing disruptive nighttime behaviors of one resident that interfered with other residents’ ability to rest. Resident #1, admitted with diagnoses including Psychosis and Dementia and a BIMS score of 4 indicating severely impaired cognition, had documented episodes of hollering and yelling during nighttime hours, as noted in progress notes on 3/12/26 and 3/13/26. Interviews with cognitively intact residents, Resident #2 and Resident #3 (both with BIMS scores of 15), revealed that they frequently experienced disrupted sleep due to Resident #1 yelling loudly at night, while the environment was generally quiet during the day. Staff interviews confirmed awareness of the pattern of behavior. CNA #1, who worked both day and night shifts, reported that Resident #1 frequently yelled and screamed at intervals throughout the night and was generally quiet and often slept during the day, with staff assisting the resident out of bed into a geri-chair during both day and nighttime hours. The DON acknowledged the facility was aware of Resident #1’s increased nighttime yelling and extended daytime rest, attributing it to the resident’s Dementia and Psychosis, and stated that interventions such as monitoring, repositioning, offering care, and attempts at redirection had not stopped the behaviors. The Administrator also confirmed awareness of concerns that nighttime noise from Resident #1 affected other residents’ ability to rest. Despite this awareness and ongoing complaints from other residents, the disruptive nighttime yelling continued, resulting in a failure to uphold residents’ rights to a dignified existence and a comfortable environment.
Failure to Ensure Privacy and Dignified Care During Incontinence Care and Feeding
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were treated with dignity and provided privacy during care, as required by resident rights policies and skills checklists. The facility’s Nursing Facility Resident Rights policy guaranteed residents the right to be treated with dignity, courtesy, and respect, and to have privacy during personal care. Facility skills checklists for feeding and peri/incontinent care specified that staff should sit facing residents at eye level when feeding and provide privacy by drawing curtains and closing doors during incontinence care. For Resident #2, surveyors observed a CNA providing incontinent care without closing the resident’s room door and with the privacy curtain only partially drawn. From the surveyor’s position at the bottom right corner of the bed, it was possible to see into the hallway while the resident was uncovered and exposed. Resident #2’s records showed admission with diagnoses including epilepsy, infection of the skin and subcutaneous tissue, an open wound of the left upper arm, and gastrostomy status. A recent MDS assessment documented a BIMS score of 11, indicating moderate cognitive impairment, and that the resident was dependent for toilet hygiene. The CNA later confirmed awareness that incontinence care required provision of privacy and that she had been trained and competency-checked on this requirement. For Resident #3, surveyors observed a CNA assisting the resident with eating while standing over the resident rather than sitting beside her, contrary to the facility’s feeding skills checklist and training. The DON intervened during the observation and instructed the CNA that staff were to sit next to residents while assisting with eating. The CNA stated she had forgotten to sit beside the resident. Resident #3’s records showed recent admission with diagnoses of cerebral infarction (stroke), anemia, and hemiplegia and hemiparesis affecting the right dominant side, and a baseline care plan indicating the resident was dependent for eating. Other staff interviews, including with a CNA supervisor, an LPN, the DON, and the Administrator, confirmed that staff were trained at least monthly on residents’ rights, respectful and dignified care, provision of privacy during incontinence care, and the expectation that staff sit beside residents when assisting with eating.
Failure to Maintain Accessible Call Light for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was maintained within reach as required by the facility’s feeding skills checklist. The skills checklist for feeding a resident specifies that staff must leave the call light within the resident’s reach after feeding. For Resident #2, surveyors observed on two separate occasions that the call light was not accessible. On one observation, the resident was awake in bed with a lunch tray on the overbed table, and the call light was found lying on the floor under the head of the bed. The resident stated he could use his call light but did not know where it was. On a subsequent observation, Resident #2 was again in bed with a lunch tray in front of him, and the call light was hanging behind the mattress at the head of the bed, out of his sight and reach. The resident again stated he could use the call light but did not know where it was. Record review showed the resident had epilepsy, an infection of the skin and subcutaneous tissue, an open wound of the left upper arm, gastrostomy status, and a BIMS score of 11 indicating moderate cognitive impairment. Staff interviews with CNAs, an LPN, the DON, and the Administrator confirmed that call lights were expected to be within residents’ reach and answered timely, and that staff had received in-service training and competency checks on leaving call lights within reach. The Administrator also confirmed there was no specific written policy regarding call light placement.
Failure to Provide Required Perineal Cleansing During Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to provide incontinent care in accordance with its own peri-care policy and professional standards of practice for a male resident who was dependent for toilet hygiene. The facility’s written policy for peri/incontinent care for male residents, revised in January 2023, required cleansing of the perineal area starting at the urethra and working outward, including washing and rinsing the penis, scrotum, inner thighs, and perineal area front and back, followed by thorough drying. Record review showed the resident had diagnoses including epilepsy, infection of the skin and subcutaneous tissue, an open wound of the left upper arm, and gastrostomy status, and a Quarterly MDS with a BIMS score of 11 indicating moderate cognitive impairment, with the resident assessed as dependent for toilet hygiene. On the observed date and time, CNA #1 provided incontinent care to this resident by removing a wet urine-soaked brief, changing the fitted sheet, and applying a clean, dry brief without cleansing the resident’s perineal area, front or back, contrary to facility policy. During a subsequent interview, CNA #1 acknowledged she had received in-service training and competency check-offs on peri-care and knew she was supposed to cleanse the perineal area but did not do so, stating she was nervous. Additional interviews with CNA #2 (CNA supervisor and scheduler), an LPN, the DON, and the Administrator confirmed that staff were trained using the Peri Care–Incontinent Care Skills Checklist and that proper incontinent care includes cleansing the perineal area, front and back, in addition to changing the brief. The failure to perform the required cleansing during incontinent care constituted the cited deficiency related to prevention of urinary tract infections.
Failure to Maintain Infection Control Practices During PEG Tube and Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program by not maintaining aseptic technique and not providing ordered dressing changes for residents with PEG tubes and a sacral pressure injury. Facility policies on infection control and clean dressing changes required wound care to be provided in a manner that decreases the potential for infection and cross-contamination, including removal of soiled dressings with gloves, discarding gloves, performing hand hygiene, and donning clean gloves before continuing care. The peri-care audit tool also required glove removal, hand hygiene, and re-gloving after peri-care. These standards were not followed during multiple observed care episodes. For one resident with a PEG tube and diagnoses including Alzheimer’s disease, functional quadriplegia, and gastrostomy status, surveyors observed the PEG tube site without a dressing and with a yellowish-brown substance beneath and around the external skin disk extending about one-fourth inch onto surrounding skin. A CNA and an LPN both confirmed there was no dressing in place and acknowledged the drainage at the site. The LPN stated PEG tube site care should be completed daily and as needed for increased drainage and acknowledged that, with no dressing and the amount of drainage present, there was no way to tell when the site was last cleaned. Record review showed a physician order, effective several months prior, for daily cleansing of the PEG tube stoma with normal saline, patting dry, and applying a dry drain dressing to avoid skin breakdown. For another resident with severe protein-calorie malnutrition and gastrostomy status, the PEG tube site was observed with thick brown, crusted substance beneath the external skin disk extending approximately one-half to three-fourths of an inch to the surrounding area. The resident reported the site had not been cleaned in about three days and later stated they might have to clean it themselves. Follow-up observations confirmed the site remained unclean with visible drainage, and an LPN and the DON both confirmed the presence of thick, brown drainage and that the site had not been cleaned in several days, despite an order for daily cleansing with soap and water, rinsing, patting dry, and leaving open to air or applying a dry dressing if drainage was present. In a separate observation involving a resident with a stage IV sacral pressure ulcer and severe cognitive impairment, a CNA provided peri-care for stool soiling, then immediately assisted with wound care using the same gloves worn during peri-care, without performing hand hygiene or changing gloves. The CNA, treatment nurse, DON, and ADON all acknowledged that hand hygiene and glove change should have occurred between peri-care and wound care and that this represented an infection control concern.
Failure to Maintain Clean Resident Rooms and Shower Facilities
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by its Resident Rights & Quality of Life Policy. For one resident, surveyors observed a bag of odorous soiled linens resting on the floor of the room, and the resident’s bed was made with a bedspread that had a football-sized hole exposing the mattress. The resident, who was cognitively intact with a BIMS score of 14 and had Type 2 Diabetes Mellitus, reported that it was not unusual for bags of soiled linens to be left on the floor and for bedding to be damaged. A CNA confirmed that soiled linens were commonly left in bags on the floor after morning care and that torn bedding should not be used, and later placed the bag of soiled linens on the resident’s furniture where his clean clothing was hanging. The resident remained upset the following day, and a dead roach was observed under his bed near the headboard. Additional deficiencies were identified in other resident rooms. One resident with End Stage Renal Disease and a severely impaired cognition (BIMS score of 5) reported that housekeeping did not clean under the bed; surveyors observed three large dead roaches under the bed, which remained there the following day. When the Housekeeping Supervisor later observed the room, five dead roaches were present under the bed, and he stated the area should not have been in that condition. Another resident, with a diffuse traumatic brain injury and a moderately impaired cognition (BIMS score of 10), reported frequently picking up and disposing of dead roaches himself because staff did not remove them, and a large dead roach was observed under his bed. The facility also failed to maintain a clean and sanitary north shower room. During a Resident Council interview, multiple cognitively intact and moderately impaired residents reported refusing to use the shower room due to cleanliness concerns, including observations of dirty clothing, feces, and residue on shower chairs and floors. A housekeeper stated that while she cleaned the shower rooms multiple times a day, CNAs were responsible for cleaning and sanitizing the shower room after each use and that she had observed occasions when CNAs failed to do so. A subsequent observation of the north shower room revealed soiled clothing, including a soiled brief, on a shower chair, a yellow fluid-like substance on the floor and shower chair, and a white powdery substance on the floor, with no staff present. The Social Services Assistant, DON, and Administrator each acknowledged that staff were expected to clean and sanitize the shower room after each use.
Ongoing Roach Activity Demonstrates Ineffective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program as required by its pest control policy dated 9/1/2014, which states the center will maintain an ongoing program to keep the building free of insects and rodents. Surveyors observed multiple instances of roach and insect activity in resident rooms and common areas. In one cognitively intact resident’s room, gnats were seen flying and a dead roach was later found under the bed near the headboard. Another resident’s room contained three large dead roaches under the bed on two consecutive days; this resident reported that roaches were regularly seen in the room, especially at night, crawling on the ceiling and falling onto him and his roommate, and that staff had been notified but he had not seen staff respond to assess or treat the issue. A third resident reported seeing roaches on the ceiling and under the bed and stated he often removed dead roaches himself because staff did not; a large dead roach was observed under his bed. A family member of another resident reported feeling it was necessary to bring her own roach spray due to concerns about roaches in the resident’s room and stated she was told she could not keep the spray in the room, expressing concern that the roach problem needed to be addressed. During a Resident Council meeting, two large roaches were observed crawling across the floor, and residents reported that roaches were commonly seen in rooms and common areas, including on walls, ceilings, and floors, particularly at night. The contracted pest control provider reported he provides monthly services, focusing on different areas each visit, primarily treating entry points and exterior areas, and stated he had not personally observed roaches and received only occasional complaints. Facility leadership, including the housekeeping supervisor, DON, and Maintenance Director, described expectations that staff report pest sightings and that pest control services are available monthly and as needed, but the ongoing presence of roaches and dead insects in resident rooms and common areas demonstrated that the pest control program was not effectively preventing or controlling pests.
Failure to Ensure Resident Access to Private Telephone Communication
Penalty
Summary
The facility failed to ensure a resident’s right to reasonable access to and privacy in the use of a telephone for communication. Facility policy on Resident Rights, revised December 2016, states that residents are guaranteed access to a telephone, mail, and email, and the ability to communicate in person and by mail, email, and telephone with privacy. Resident #1 was admitted on 12/18/24 with diagnoses including Sjogren syndrome, rheumatoid arthritis, chronic kidney disease, and morbid obesity. During an interview, the resident reported that she had dropped and broken her personal cellular telephone, which she had used for private communication, and that the facility did not have any telephone that was convenient for her to use privately. She stated that no staff had offered her the use of a staff office or any other mechanism for private communication, and she was upset because she relied on telephone contact with her significant other, who had cancer and was unable to visit. Observations and staff interviews confirmed the lack of accessible, private telephone options for residents on South Hall. An observation on the 100 Hall revealed there was no cordless telephone available for resident use. The DON confirmed that the facility did not have a method to provide residents on South Hall with private communication without first making arrangements or an appointment to use a staff office, and that the cordless telephones in the facility did not have sufficient range to reach South Hall. The SSD confirmed there were no cordless telephones at the South Hall nurses’ station that could be taken to residents’ rooms and acknowledged that Resident #1’s cell phone had been broken and sent out for repair. The Administrator also confirmed that residents on South Hall did not have a method for private communication without prior arrangements and acknowledged that access to private communication is a guaranteed resident right.
Failure to Provide Adequate ADL Assistance for Personal Hygiene
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) to maintain personal hygiene for one resident who was dependent on staff for care. Facility policy on ADLs, revised March 2018, stated that residents unable to carry out ADLs independently would receive services necessary to maintain good grooming and personal and oral hygiene. Record review showed the resident was admitted with heart failure, chronic kidney disease, and hypertension, had a BIMS score of 12 indicating moderate cognitive impairment, was always incontinent of bowel and bladder, and required substantial/maximal assistance for personal hygiene and was dependent for toilet hygiene. A complainant reported that the resident had expressed difficulty getting staff to provide assistance with ADLs. During an observation and interview with the resident, accompanied by an LPN, the resident reported ongoing difficulty obtaining assistance with ADLs. The surveyor observed that the resident had ten long, dirty fingernails protruding 3.0 to 3.5 millimeters past the fingertips, with a black substance beneath all fingernails; the resident stated they needed cleaning and cutting and were too long. The LPN described the fingernails as too long and dirty, confirmed that nursing staff were responsible for checking fingernails daily during care and weekly during body audits, and acknowledged that staff were responsible for providing fingernail care as part of ADLs. The LPN also confirmed that long, dirty, unkempt fingernails had the potential to cause damage or scratches to the resident’s skin. The DON stated she was not aware of any complaints from the resident but confirmed her expectation that ADLs for residents dependent on staff for personal hygiene would be maintained and provided as needed, and that licensed nurses trimmed fingernails for some residents while any nursing staff could clean under fingernails. The Administrator confirmed that personal hygiene and grooming were part of resident ADLs and were expected to be provided for all dependent residents.
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