Grenada Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Grenada, Mississippi.
- Location
- 1966 Hill Drive, Grenada, Mississippi 38901
- CMS Provider Number
- 255156
- Inspections on file
- 19
- Latest survey
- April 6, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Grenada Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A cognitively intact, fully dependent resident with a right BKA and multiple rib fractures remained in a soiled brief and heavily soiled bed linens for an extended period after a bowel movement, despite pressing the call light and being briefly checked by staff who did not return. The resident expressed embarrassment, humiliation, and a desire to leave, and his representative reported finding him "in a mess," notifying staff at the nursing desk, and observing a nurse enter and then leave the room without care being provided. Later, the ADM and DON observed the resident still lying in feces-soiled linens and acknowledged that he relied on staff for all ADLs and that his condition was unacceptable and a dignity issue.
A resident who was cognitively intact but fully dependent on staff for ADLs, including incontinence care, was observed lying in bed with fecal matter smeared on the bed pad and sheets after a bowel movement. The resident reported having been in a soiled brief for over an hour and expressed embarrassment and distress. After the resident activated the call light, a staff member entered only to deactivate it and leave without providing care. The resident’s representative later found the resident still soiled, notified staff at the nursing desk, and observed a nurse enter and then leave after texting a CNA. The CNA acknowledged being notified by an LPN that the resident needed changing but prioritized passing lunch trays and feeding another resident instead of providing incontinence care or seeking assistance. The resident remained in the soiled brief until the CNA finally entered with supplies nearly two hours after the initial observation.
A resident, who was cognitively intact and had a history of cerebral infarction, was physically abused by a CNA who forcefully pushed the resident onto the bed during care. The incident was witnessed by another CNA, and peer interviews indicated the CNA had previously spoken roughly to residents. The resident confirmed the abuse at the time, and the CNA denied the allegation, but the event was substantiated through investigation.
The facility did not maintain adequate nursing staff, leading to prolonged call-light response times and delays in care for multiple residents, including those with high-acuity needs such as incontinence and tracheostomy care. Staff and family interviews confirmed frequent staff shortages, excessive call-ins, and high resident-to-CNA ratios, resulting in unmet care needs and repeated complaints.
A resident with a history of cerebral infarction was transferred to the emergency room, but the facility did not provide the required written transfer notice to the resident's representative. The Administrator confirmed that no written notification was sent, as the resident returned within a few hours and staff did not think it was necessary.
The facility failed to submit accurate PBJ data for Q2 2024, resulting in a deficiency due to excessively low reported weekend staffing. Errors occurred because administrative nurses did not consistently submit forms for weekend shifts, and the DON's hours were not accurately captured. Despite adequate staffing, reporting inconsistencies led to the issue.
A facility failed to report an abuse allegation involving a resident and a CNA within the required timeframe. The incident, witnessed by an NA, involved inappropriate contact by the resident and a retaliatory action by the CNA. The NA delayed reporting the incident until the next day, leading to a deficiency finding.
A respiratory therapist at the facility failed to complete competency skills check-off and Enhanced Barrier Precautions training before caring for a resident with a tracheostomy. The therapist performed care without proper PPE, unaware of the resident's precaution status. Interviews revealed a lack of oversight and training, with the DON and ADON confirming the therapist was not included in previous training sessions. The facility also lacked a policy for competency skills check-offs.
A respiratory therapist failed to follow Enhanced Barrier Precautions during tracheostomy care for a resident, neglecting to wear a protective gown and perform proper hand hygiene. Despite an EBP sign on the door, the RT was unaware of the requirements, leading to potential infection risks. The facility's Director of Nurses confirmed the breach in infection control standards.
A facility failed to complete an Annual MDS for a resident within the required timeframe, exceeding the 14-day limit set by CMS. The resident's assessment reference date was June 6, 2024, but the completion date was July 1, 2024. Interviews with the MDS Coordinator and Consultant revealed ongoing issues with timely MDS completion, despite an action plan being in place. The resident had been admitted with a diagnosis of Transient Cerebral Ischemic Attack.
A facility failed to complete a Quarterly MDS for a resident with Cerebral Palsy within the required timeframe, exceeding the 14-day limit after the ARD. The MDS Coordinator and Consultant acknowledged ongoing issues with timely MDS completion, despite an action plan in place, citing time management as a contributing factor.
Failure to Timely Respond to Call Light and Provide Incontinence Care, Compromising Resident Dignity
Penalty
Summary
The deficiency involves the facility’s failure to respond in a timely manner to a resident’s request for assistance with incontinence care, resulting in the resident remaining in a soiled brief and bed for an extended period. On 04/06/26 at 11:00 AM, a cognitively intact resident with a right below-knee amputation, multiple left rib fractures, and dependence on staff for all ADLs, transfers, turning, and repositioning was observed lying in bed with multiple large smears of yellowish fecal matter on his bed pad, fitted sheet, and flat sheet. The resident attempted to cover the soiled areas with the clean part of the top sheet and reported he had a bowel movement and had been lying in a dirty diaper for over an hour while waiting for someone to come and change him. At 11:08 AM, he pressed his call light for assistance. At 12:23 PM, the same resident was again observed in the same position, still in a soiled brief with yellow fecal matter smeared on the bed pad and sheets. He stated that the situation made him feel bad, that no one else would want to lie like that, and that he felt embarrassed, upset, and wanted to leave as soon as he could. He confirmed that someone had come in earlier, saw what he needed, left to get help, and did not return. The resident’s representative, present from 12:00 PM, reported finding him “in a mess” with a large bowel movement all over him and his bed, and stated that when he saw her, he was embarrassed and tried to cover it with his sheet. She reported notifying staff at the nursing desk and observing a nurse enter the room and then leave and text someone, yet no one came to provide care. At 12:46 PM, the Administrator and DON observed the resident still lying in a soiled brief with fecal matter on the bed pad and sheets and acknowledged that he could not care for himself, depended on staff to meet his needs, and that this situation was not acceptable and was a dignity issue.
Failure to Provide Timely Incontinence Care and ADL Assistance
Penalty
Summary
The facility failed to provide timely incontinence care and assistance with activities of daily living for a resident who was dependent on staff for all ADLs, transfers, turning, and repositioning. The resident had a right below-the-knee amputation, multiple left rib fractures, and a history of traumatic subarachnoid hemorrhage, and was cognitively intact with a BIMS score of 13. Facility policy on ADL support stated that residents unable to carry out ADLs independently would receive services necessary to maintain good grooming, personal, and oral hygiene. On the survey date at 11:00 AM, the resident was observed lying in bed with multiple large smears of yellowish fecal matter on the bed pad, fitted sheet, and flat sheet. The resident attempted to cover the soiled area with a clean part of the top sheet and reported having had a bowel movement and lying in a dirty brief for over an hour while waiting for someone to come and change him. At 11:08 AM, the resident pressed the call light, and at 11:11 AM an unidentified staff member entered the room, deactivated the call light, and exited without providing incontinence care. At 12:23 PM, the resident was again observed in the same position, still in a soiled brief with fecal matter smeared on the bed linens, stating that the situation made him feel bad, embarrassed, and upset, and that he wanted to leave as soon as he could. The resident’s representative reported arriving around noon, finding the resident in a large bowel movement “all over him and his bed,” and observing that he tried to cover it up when she entered due to embarrassment. She stated she notified staff at the nursing desk that he needed help, but no one came, and that she saw a nurse enter the room and then leave to text someone. CNA #1 stated that LPN #1 had notified her earlier that the resident needed to be changed and that she intended to care for him next but instead passed lunch trays and fed another resident, acknowledging she was very busy and should have changed him sooner or asked for help. LPN #1 confirmed that the resident’s sister had requested assistance, that she told the resident she would get help and texted CNA #1, but did not follow up to ensure care was provided. At 12:46 PM, the Administrator and DON observed the resident still lying in a soiled brief with fecal matter on the bed pad and sheets and confirmed this was not acceptable, and at 12:50 PM CNA #1 finally entered with supplies to provide care, approximately one hour and fifty minutes after the initial observation.
Resident Physically Abused by CNA During Care
Penalty
Summary
A deficiency occurred when a Certified Nurse Assistant (CNA) physically abused a resident by forcefully pushing the resident down onto the bed. The incident was witnessed by another CNA, who reported that the resident was standing beside his bed and refusing assistance when the CNA entered the room and pushed him hard enough to cause him to fall backward onto the bed. The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 and had a history of cerebral infarction, confirmed at the time of the incident that the CNA had pushed him. During a subsequent interview, the resident became withdrawn and did not wish to discuss the event further. The facility's Abuse Prohibition Policy defines physical abuse to include actions such as shoving and requires immediate reporting and removal of accused staff from resident care duties pending investigation. Peer interviews revealed that some staff had previously heard the CNA speak roughly to residents. The CNA involved denied the allegation during a phone interview, stating she only assisted the resident, but documentation and witness statements substantiated the occurrence of physical abuse. The CNA had received abuse-prevention training prior to the incident.
Failure to Provide Sufficient Nursing Staff Resulting in Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient qualified nursing staff at all times to meet the needs of its residents, as evidenced by prolonged call-light response times and delays in assistance with care needs. Interviews with residents, family members, and staff revealed that residents often waited up to an hour or more for help, particularly with toileting and incontinence care. One resident with an overactive bladder reported frequent episodes of incontinence due to long wait times, while another resident, who required extensive assistance due to a tracheostomy and anoxic brain damage, had to rely on a privately hired sitter because staff were not available to provide timely care. Staff interviews confirmed that excessive call-ins and staff shortages were common, resulting in high resident-to-CNA ratios, especially on weekends and night shifts. Certified Nurse Assistants and LPNs reported caring for as many as 15 to 16 residents each, with many residents requiring two-person assistance due to high acuity and total-care needs. The Director of Nursing, Assistant Director of Nursing, and Administrator all acknowledged ongoing staffing concerns, frequent complaints from residents and families, and the inability to consistently cover shifts when staff called in. Review of staffing records showed that on several occasions, only three or four CNAs were available per shift to care for nearly 90 to 95 residents across multiple wings, including a specialized tracheostomy unit. The facility's own policy required sufficient and competent nursing staff to meet resident needs, but interviews and documentation demonstrated that this standard was not met, resulting in delays in care and unmet resident needs.
Failure to Provide Written Transfer Notice to Resident Representative
Penalty
Summary
The facility failed to provide a written transfer notice to a resident's representative when the resident was transferred to the emergency room. According to the facility's own policy, both the resident and their representative must be notified in writing of the specific reason for transfer, the effective date, and the location of transfer or discharge. Record review showed that the resident, who had a diagnosis of cerebral infarction, was transferred to the emergency room, but no written notification was sent to the representative. During an interview, the Administrator confirmed that no written notification was provided because the resident returned within a few hours, and staff did not believe it was necessary in this situation.
Inaccurate PBJ Data Submission Leads to Staffing Deficiency
Penalty
Summary
The facility failed to submit accurate data into the Payroll-Based Journal (PBJ) system for the second quarter of 2024, resulting in a deficiency. The PBJ Staffing Data Report for Fiscal Year Quarter 2, 2024, indicated excessively low weekend staffing, which was triggered by incorrect data submission. Interviews revealed that the Human Resources/Payroll Coordinator relied on administrative nurses to submit forms for weekend shifts, which were not consistently provided. The Director of Nurses (DON) admitted to working many weekend shifts but was unsure if she submitted the necessary forms. The Corporate Consultant confirmed that the hours worked by the DON and a treatment nurse were not accurately captured in the PBJ report due to errors in data entry. Despite being adequately staffed, inconsistencies in reporting led to the deficiency.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency within the required two-hour timeframe. This deficiency involved Resident #58 and was based on interviews, record reviews, and facility policy examination. The facility's Abuse Prohibition Policy mandates that any employee aware of an abuse allegation must report it immediately to the Abuse Coordinator. However, Nursing Assistant (NA) #1 did not report an incident involving Certified Nursing Assistant (CNA) #1 and Resident #58 until the following day. During the incident, Resident #58 reportedly touched CNA #1 inappropriately, and CNA #1 responded by hitting the resident with his own hand. NA #1 witnessed the event but delayed reporting it due to CNA #1's presence. Further investigation revealed that Registered Nurse (RN) #1 was not informed of the incident by NA #1 on the day it occurred, despite being in the room shortly after the event. The Director of Nursing (DON) confirmed that the facility was unaware of the incident until the day after it happened. As a result, NA #1 was suspended pending investigation for failing to report the abuse allegation immediately, as required by the facility's policy. The disciplinary action record was signed by NA #1, acknowledging the delay in reporting.
Failure to Ensure Competency and Training for Respiratory Therapist
Penalty
Summary
The facility failed to ensure that staff completed competency skills check-off and Enhanced Barrier Precautions training before caring for residents with a tracheostomy. This deficiency was identified in the case of a respiratory therapist (RT) who was observed performing tracheostomy care for a resident without wearing the appropriate personal protective equipment, specifically a gown, despite the presence of an Enhanced Barrier Precaution sign on the resident's door. The RT admitted to not being aware of the resident's precaution status and confirmed that she had not received training on enhanced barrier precautions. Interviews with the Director of Nurses (DON), Assistant Director of Nurses (ADON), and the Respiratory Therapist Director revealed a lack of awareness and oversight regarding the RT's training status. The DON and ADON confirmed that all nursing staff were supposed to be trained on enhanced barrier precautions, but the RT had not been included in the training sessions conducted in September 2023. Additionally, the RT did not have a competency skill check-off for tracheostomy care, despite being employed part-time since 2022. The facility lacked a policy for competency skills check-offs, contributing to the oversight.
Infection Control Breach During Tracheostomy Care
Penalty
Summary
The facility failed to adhere to its infection prevention and control program during the care of a resident with a tracheostomy. The respiratory therapist (RT) did not follow Enhanced Barrier Precautions (EBP) as required by the facility's policy. Despite the presence of an EBP sign on the resident's door, the RT entered the room without wearing a protective gown and performed tracheostomy care without proper hand hygiene. The RT applied sterile gloves over soiled gloves and failed to wash her hands between the dirty and clean processes, which is against the facility's standards of practice for tracheostomy care. The RT admitted to not being aware of the need for a gown and proper hand hygiene, revealing a lack of training in EBP. The Director of Nurses and the Respiratory Director confirmed that the RT's actions were not in line with the facility's infection control standards, acknowledging the potential risk of infection to the resident. The resident involved had been admitted with diagnoses including pneumonitis due to inhalation of food and vomit, cerebral infarction, and required attention to a tracheostomy.
Late Completion of MDS Assessment
Penalty
Summary
The facility failed to complete an Annual Minimum Data Set (MDS) for a resident within the required timeframe, as mandated by the Centers for Medicare and Medicaid Services (CMS). Specifically, the MDS for a resident was completed more than 14 days after the Assessment Reference Date (ARD), which is a violation of the facility's policy and CMS guidelines. The resident's assessment reference date was documented as June 6, 2024, but the assessment completion date was recorded as July 1, 2024, exceeding the permissible 14-day period. Interviews with the MDS Coordinator and MDS Consultant revealed awareness of ongoing issues with timely MDS completion and submission. Despite an action plan being in place for about a year to address these problems, the issues persist, with time management cited as a contributing factor. The MDS Consultant acknowledged the need to alter the existing plan to prevent late assessments, emphasizing the importance of timely MDS completion for accurate billing and resident care planning. The resident involved had been admitted with a diagnosis of Transient Cerebral Ischemic Attack.
Failure to Timely Complete MDS Assessment
Penalty
Summary
The facility failed to complete a Quarterly Minimum Data Set (MDS) for a resident within the required timeframe, as mandated by the Centers for Medicare and Medicaid Services (CMS). Specifically, the MDS for a resident was completed more than 14 days after the Assessment Reference Date (ARD), which is a violation of the facility's policy and CMS guidelines. The resident in question was admitted with a diagnosis of Cerebral Palsy, and the assessment was crucial for ensuring accurate billing and the development of an appropriate plan of care. The MDS Coordinator confirmed that the assessment was completed late and acknowledged that the facility has had ongoing issues with timely MDS completion. Despite being on an action plan for about a year to address these problems, the issues persist, partly due to time management challenges. The MDS Consultant also confirmed awareness of the facility's issues with MDS completion and submission, indicating that the existing plan of action needed adjustments to prevent future late assessments.
Latest citations in Mississippi
A resident with advanced dementia and severe cognitive impairment sustained a bruised left eye and facial bruising after being struck by a CNA. The CNA initially claimed the injury occurred accidentally while pushing the resident to a dining table and denied hitting the resident, but an LPN and another CNA reported that the resident stated she had hit the CNA and was hit back in the eye, demonstrating a slapping motion. Nursing documentation described left orbital ecchymosis, bruising along the bridge of the nose and cheek, tenderness, minimal edema, and the resident’s complaint of soreness, confirming a significant injury resulting from the physical abuse.
The facility failed to protect residents’ right to a dignified and comfortable environment when it did not effectively manage one cognitively impaired resident’s ongoing nighttime yelling, which repeatedly disrupted the sleep of two cognitively intact residents. Staff, including a CNA, the DON, and the Administrator, were aware that this resident, diagnosed with dementia and psychosis, frequently yelled and screamed at night while often sleeping during the day. Progress notes documented nighttime hollering, and interviews confirmed that the disruptive behavior persisted over time, interfering with other residents’ ability to rest.
Surveyors found that the facility failed to protect two residents’ rights to dignity and privacy during routine care. One resident, with moderate cognitive impairment and dependent for toilet hygiene, was observed receiving incontinence care while uncovered, with the room door open and the privacy curtain only partially drawn, allowing visibility into the hallway despite facility policy requiring full privacy. Another resident, dependent for eating and with hemiplegia after a stroke, was assisted with lunch by a CNA who stood over the resident instead of sitting at eye level as required by the facility’s feeding skills checklist. Staff interviews, including with CNAs, an LPN, the DON, and the Administrator, confirmed that existing policies and in-service training directed staff to provide privacy during incontinence care and to sit beside residents when assisting with meals to ensure dignified care.
A resident with epilepsy, skin infection, an upper arm wound, gastrostomy status, and moderate cognitive impairment was observed twice resting in bed with a lunch tray while the call light was not within reach—once on the floor under the bed and once hanging behind the mattress, out of sight. The resident reported being able to use the call light but not knowing where it was. Staff, including CNAs, an LPN, the DON, and the Administrator, stated that call lights are expected to be left within residents’ reach and that training and competencies address this requirement, but there was no specific written policy on call light placement.
A resident with moderate cognitive impairment, dependent for toilet hygiene and with multiple medical conditions, was observed receiving incontinent care in which a CNA removed a urine-soaked brief, changed the bed sheet, and applied a clean brief without performing any required perineal cleansing of the front or back. Facility policy and the peri-care skills checklist specified that male residents must have the perineal area, including the penis, scrotum, and inner thighs, washed, rinsed, and dried during incontinent care. The CNA later acknowledged having been trained and competency-checked on this procedure and knowing cleansing was required. Other staff, including a CNA supervisor, an LPN, the DON, and the Administrator, confirmed that proper incontinent care includes full perineal cleansing in addition to brief changes, establishing that the observed omission did not follow facility policy or professional standards intended to prevent UTIs.
Surveyors found that staff failed to follow infection control practices during PEG tube and wound care. Two residents with PEG tubes had sites with visible brown, crusted or yellowish drainage that had not been cleaned for several days, despite physician orders for daily cleansing and, when indicated, dressings. In another case, a CNA provided peri-care for stool and then assisted with a stage IV sacral pressure ulcer dressing change without changing gloves or performing hand hygiene, contrary to facility policy and staff expectations for aseptic technique.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment when a resident’s room contained odorous soiled linens left on the floor and later placed on furniture with clean clothing, and the bed was made with torn linens exposing the mattress. Other residents reported that housekeeping did not clean under beds, and multiple large dead roaches were repeatedly observed under several beds, with one resident stating he often disposed of dead roaches himself. Residents also reported refusing to use the north shower room due to dirty clothing, feces, and residue on shower chairs and floors; an observation confirmed the presence of soiled clothing, a soiled brief, and unidentified substances on the shower chair and floor, despite staff acknowledging that CNAs were expected to clean and sanitize the shower room after each use.
The facility failed to maintain an effective pest control program, as evidenced by repeated observations of roaches and other insects in multiple resident rooms and common areas. Surveyors found gnats and dead roaches under beds, while several residents reported seeing roaches on ceilings, walls, and floors, including roaches falling onto them at night and having to remove dead roaches themselves. A family member reported bringing her own roach spray due to concerns about roaches in a loved one’s room. During a Resident Council meeting, roaches were seen crawling across the floor, and residents stated that roaches were commonly observed throughout the building. Although the contracted pest control provider reported monthly service focused mainly on entry points and exterior areas and facility staff described processes for reporting pests, the persistent roach activity showed the program was not effectively preventing or controlling pests.
A resident with multiple chronic conditions, who relied on phone contact with a seriously ill significant other, lost access to private communication after her personal cell phone was broken and sent out for repair. Facility policy guarantees residents access to a telephone and private communication, but there was no cordless phone available on the relevant hall, and staff, including the DON, SSD, and Administrator, confirmed there was no convenient method for residents on that hall to make private calls without arranging to use a staff office. This resulted in the resident having no readily available, private telephone option.
A resident with heart failure, chronic kidney disease, hypertension, moderate cognitive impairment, and total dependence on staff for personal and toilet hygiene reported difficulty obtaining assistance with ADLs. Observation revealed the resident had ten long, dirty fingernails extending several millimeters beyond the fingertips with black material underneath, and the resident stated they needed cleaning and cutting. An LPN confirmed the nails were too long and dirty, acknowledged that nursing staff were responsible for daily and weekly fingernail checks and for providing fingernail care as part of ADLs, and noted that such nails could cause skin damage or scratches. The DON and Administrator both confirmed that personal hygiene and grooming are part of ADLs and are expected to be provided for all residents dependent on staff.
Failure to Protect Cognitively Impaired Resident From Physical Abuse by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse, resulting in the resident being struck in the eye by a CNA. Facility records show that a CNA reported to an LPN that the resident had a bruised left eye and initially stated the injury may have occurred while pushing the resident to the dining table due to the resident’s short, stooped posture. The CNA also reported that the resident used a racial slur toward her and that she verbally responded but denied striking the resident. However, subsequent interviews and the facility’s investigation determined that the resident’s injury was not caused by accidental contact with the dining table. Interviews with staff revealed conflicting accounts that led to the conclusion that the resident had been hit. An LPN stated that the resident reported being hit in the eye by the CNA and that another CNA heard a commotion and later observed bruising to the resident’s left eye. When this second CNA asked what happened, the resident reported that she hit the CNA and was hit back in the eye, while making a motion consistent with a slap. The LPN confirmed that the resident gave a similar account to her, indicating that the CNA had physically struck the resident. The resident involved was admitted to the Memory Care Unit with diagnoses including Alzheimer’s disease, cognitive communication deficit, and unspecified dementia with behavioral disturbance, and had a BIMS score of 5 indicating severe cognitive impairment. A nursing progress note documented an acute follow-up assessment of left orbital ecchymosis, describing a dark red circular bruise to the left eye region, dark purple bruising along the lateral bridge of the nose extending to the superior left cheek, tenderness on palpation, minimal edema, and the resident’s complaint that the area was sore. Due to advanced Alzheimer’s disease, the resident was unable to reliably express additional symptoms, but the documented physical findings supported that the resident sustained a significant injury to the eye area as a result of being struck by the CNA.
Failure to Protect Residents’ Right to Rest Due to Unmanaged Nighttime Yelling
Penalty
Summary
The deficiency involves the facility’s failure to ensure a dignified and comfortable environment by not effectively addressing ongoing disruptive nighttime behaviors of one resident that interfered with other residents’ ability to rest. Resident #1, admitted with diagnoses including Psychosis and Dementia and a BIMS score of 4 indicating severely impaired cognition, had documented episodes of hollering and yelling during nighttime hours, as noted in progress notes on 3/12/26 and 3/13/26. Interviews with cognitively intact residents, Resident #2 and Resident #3 (both with BIMS scores of 15), revealed that they frequently experienced disrupted sleep due to Resident #1 yelling loudly at night, while the environment was generally quiet during the day. Staff interviews confirmed awareness of the pattern of behavior. CNA #1, who worked both day and night shifts, reported that Resident #1 frequently yelled and screamed at intervals throughout the night and was generally quiet and often slept during the day, with staff assisting the resident out of bed into a geri-chair during both day and nighttime hours. The DON acknowledged the facility was aware of Resident #1’s increased nighttime yelling and extended daytime rest, attributing it to the resident’s Dementia and Psychosis, and stated that interventions such as monitoring, repositioning, offering care, and attempts at redirection had not stopped the behaviors. The Administrator also confirmed awareness of concerns that nighttime noise from Resident #1 affected other residents’ ability to rest. Despite this awareness and ongoing complaints from other residents, the disruptive nighttime yelling continued, resulting in a failure to uphold residents’ rights to a dignified existence and a comfortable environment.
Failure to Ensure Privacy and Dignified Care During Incontinence Care and Feeding
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were treated with dignity and provided privacy during care, as required by resident rights policies and skills checklists. The facility’s Nursing Facility Resident Rights policy guaranteed residents the right to be treated with dignity, courtesy, and respect, and to have privacy during personal care. Facility skills checklists for feeding and peri/incontinent care specified that staff should sit facing residents at eye level when feeding and provide privacy by drawing curtains and closing doors during incontinence care. For Resident #2, surveyors observed a CNA providing incontinent care without closing the resident’s room door and with the privacy curtain only partially drawn. From the surveyor’s position at the bottom right corner of the bed, it was possible to see into the hallway while the resident was uncovered and exposed. Resident #2’s records showed admission with diagnoses including epilepsy, infection of the skin and subcutaneous tissue, an open wound of the left upper arm, and gastrostomy status. A recent MDS assessment documented a BIMS score of 11, indicating moderate cognitive impairment, and that the resident was dependent for toilet hygiene. The CNA later confirmed awareness that incontinence care required provision of privacy and that she had been trained and competency-checked on this requirement. For Resident #3, surveyors observed a CNA assisting the resident with eating while standing over the resident rather than sitting beside her, contrary to the facility’s feeding skills checklist and training. The DON intervened during the observation and instructed the CNA that staff were to sit next to residents while assisting with eating. The CNA stated she had forgotten to sit beside the resident. Resident #3’s records showed recent admission with diagnoses of cerebral infarction (stroke), anemia, and hemiplegia and hemiparesis affecting the right dominant side, and a baseline care plan indicating the resident was dependent for eating. Other staff interviews, including with a CNA supervisor, an LPN, the DON, and the Administrator, confirmed that staff were trained at least monthly on residents’ rights, respectful and dignified care, provision of privacy during incontinence care, and the expectation that staff sit beside residents when assisting with eating.
Failure to Maintain Accessible Call Light for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was maintained within reach as required by the facility’s feeding skills checklist. The skills checklist for feeding a resident specifies that staff must leave the call light within the resident’s reach after feeding. For Resident #2, surveyors observed on two separate occasions that the call light was not accessible. On one observation, the resident was awake in bed with a lunch tray on the overbed table, and the call light was found lying on the floor under the head of the bed. The resident stated he could use his call light but did not know where it was. On a subsequent observation, Resident #2 was again in bed with a lunch tray in front of him, and the call light was hanging behind the mattress at the head of the bed, out of his sight and reach. The resident again stated he could use the call light but did not know where it was. Record review showed the resident had epilepsy, an infection of the skin and subcutaneous tissue, an open wound of the left upper arm, gastrostomy status, and a BIMS score of 11 indicating moderate cognitive impairment. Staff interviews with CNAs, an LPN, the DON, and the Administrator confirmed that call lights were expected to be within residents’ reach and answered timely, and that staff had received in-service training and competency checks on leaving call lights within reach. The Administrator also confirmed there was no specific written policy regarding call light placement.
Failure to Provide Required Perineal Cleansing During Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to provide incontinent care in accordance with its own peri-care policy and professional standards of practice for a male resident who was dependent for toilet hygiene. The facility’s written policy for peri/incontinent care for male residents, revised in January 2023, required cleansing of the perineal area starting at the urethra and working outward, including washing and rinsing the penis, scrotum, inner thighs, and perineal area front and back, followed by thorough drying. Record review showed the resident had diagnoses including epilepsy, infection of the skin and subcutaneous tissue, an open wound of the left upper arm, and gastrostomy status, and a Quarterly MDS with a BIMS score of 11 indicating moderate cognitive impairment, with the resident assessed as dependent for toilet hygiene. On the observed date and time, CNA #1 provided incontinent care to this resident by removing a wet urine-soaked brief, changing the fitted sheet, and applying a clean, dry brief without cleansing the resident’s perineal area, front or back, contrary to facility policy. During a subsequent interview, CNA #1 acknowledged she had received in-service training and competency check-offs on peri-care and knew she was supposed to cleanse the perineal area but did not do so, stating she was nervous. Additional interviews with CNA #2 (CNA supervisor and scheduler), an LPN, the DON, and the Administrator confirmed that staff were trained using the Peri Care–Incontinent Care Skills Checklist and that proper incontinent care includes cleansing the perineal area, front and back, in addition to changing the brief. The failure to perform the required cleansing during incontinent care constituted the cited deficiency related to prevention of urinary tract infections.
Failure to Maintain Infection Control Practices During PEG Tube and Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program by not maintaining aseptic technique and not providing ordered dressing changes for residents with PEG tubes and a sacral pressure injury. Facility policies on infection control and clean dressing changes required wound care to be provided in a manner that decreases the potential for infection and cross-contamination, including removal of soiled dressings with gloves, discarding gloves, performing hand hygiene, and donning clean gloves before continuing care. The peri-care audit tool also required glove removal, hand hygiene, and re-gloving after peri-care. These standards were not followed during multiple observed care episodes. For one resident with a PEG tube and diagnoses including Alzheimer’s disease, functional quadriplegia, and gastrostomy status, surveyors observed the PEG tube site without a dressing and with a yellowish-brown substance beneath and around the external skin disk extending about one-fourth inch onto surrounding skin. A CNA and an LPN both confirmed there was no dressing in place and acknowledged the drainage at the site. The LPN stated PEG tube site care should be completed daily and as needed for increased drainage and acknowledged that, with no dressing and the amount of drainage present, there was no way to tell when the site was last cleaned. Record review showed a physician order, effective several months prior, for daily cleansing of the PEG tube stoma with normal saline, patting dry, and applying a dry drain dressing to avoid skin breakdown. For another resident with severe protein-calorie malnutrition and gastrostomy status, the PEG tube site was observed with thick brown, crusted substance beneath the external skin disk extending approximately one-half to three-fourths of an inch to the surrounding area. The resident reported the site had not been cleaned in about three days and later stated they might have to clean it themselves. Follow-up observations confirmed the site remained unclean with visible drainage, and an LPN and the DON both confirmed the presence of thick, brown drainage and that the site had not been cleaned in several days, despite an order for daily cleansing with soap and water, rinsing, patting dry, and leaving open to air or applying a dry dressing if drainage was present. In a separate observation involving a resident with a stage IV sacral pressure ulcer and severe cognitive impairment, a CNA provided peri-care for stool soiling, then immediately assisted with wound care using the same gloves worn during peri-care, without performing hand hygiene or changing gloves. The CNA, treatment nurse, DON, and ADON all acknowledged that hand hygiene and glove change should have occurred between peri-care and wound care and that this represented an infection control concern.
Failure to Maintain Clean Resident Rooms and Shower Facilities
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by its Resident Rights & Quality of Life Policy. For one resident, surveyors observed a bag of odorous soiled linens resting on the floor of the room, and the resident’s bed was made with a bedspread that had a football-sized hole exposing the mattress. The resident, who was cognitively intact with a BIMS score of 14 and had Type 2 Diabetes Mellitus, reported that it was not unusual for bags of soiled linens to be left on the floor and for bedding to be damaged. A CNA confirmed that soiled linens were commonly left in bags on the floor after morning care and that torn bedding should not be used, and later placed the bag of soiled linens on the resident’s furniture where his clean clothing was hanging. The resident remained upset the following day, and a dead roach was observed under his bed near the headboard. Additional deficiencies were identified in other resident rooms. One resident with End Stage Renal Disease and a severely impaired cognition (BIMS score of 5) reported that housekeeping did not clean under the bed; surveyors observed three large dead roaches under the bed, which remained there the following day. When the Housekeeping Supervisor later observed the room, five dead roaches were present under the bed, and he stated the area should not have been in that condition. Another resident, with a diffuse traumatic brain injury and a moderately impaired cognition (BIMS score of 10), reported frequently picking up and disposing of dead roaches himself because staff did not remove them, and a large dead roach was observed under his bed. The facility also failed to maintain a clean and sanitary north shower room. During a Resident Council interview, multiple cognitively intact and moderately impaired residents reported refusing to use the shower room due to cleanliness concerns, including observations of dirty clothing, feces, and residue on shower chairs and floors. A housekeeper stated that while she cleaned the shower rooms multiple times a day, CNAs were responsible for cleaning and sanitizing the shower room after each use and that she had observed occasions when CNAs failed to do so. A subsequent observation of the north shower room revealed soiled clothing, including a soiled brief, on a shower chair, a yellow fluid-like substance on the floor and shower chair, and a white powdery substance on the floor, with no staff present. The Social Services Assistant, DON, and Administrator each acknowledged that staff were expected to clean and sanitize the shower room after each use.
Ongoing Roach Activity Demonstrates Ineffective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program as required by its pest control policy dated 9/1/2014, which states the center will maintain an ongoing program to keep the building free of insects and rodents. Surveyors observed multiple instances of roach and insect activity in resident rooms and common areas. In one cognitively intact resident’s room, gnats were seen flying and a dead roach was later found under the bed near the headboard. Another resident’s room contained three large dead roaches under the bed on two consecutive days; this resident reported that roaches were regularly seen in the room, especially at night, crawling on the ceiling and falling onto him and his roommate, and that staff had been notified but he had not seen staff respond to assess or treat the issue. A third resident reported seeing roaches on the ceiling and under the bed and stated he often removed dead roaches himself because staff did not; a large dead roach was observed under his bed. A family member of another resident reported feeling it was necessary to bring her own roach spray due to concerns about roaches in the resident’s room and stated she was told she could not keep the spray in the room, expressing concern that the roach problem needed to be addressed. During a Resident Council meeting, two large roaches were observed crawling across the floor, and residents reported that roaches were commonly seen in rooms and common areas, including on walls, ceilings, and floors, particularly at night. The contracted pest control provider reported he provides monthly services, focusing on different areas each visit, primarily treating entry points and exterior areas, and stated he had not personally observed roaches and received only occasional complaints. Facility leadership, including the housekeeping supervisor, DON, and Maintenance Director, described expectations that staff report pest sightings and that pest control services are available monthly and as needed, but the ongoing presence of roaches and dead insects in resident rooms and common areas demonstrated that the pest control program was not effectively preventing or controlling pests.
Failure to Ensure Resident Access to Private Telephone Communication
Penalty
Summary
The facility failed to ensure a resident’s right to reasonable access to and privacy in the use of a telephone for communication. Facility policy on Resident Rights, revised December 2016, states that residents are guaranteed access to a telephone, mail, and email, and the ability to communicate in person and by mail, email, and telephone with privacy. Resident #1 was admitted on 12/18/24 with diagnoses including Sjogren syndrome, rheumatoid arthritis, chronic kidney disease, and morbid obesity. During an interview, the resident reported that she had dropped and broken her personal cellular telephone, which she had used for private communication, and that the facility did not have any telephone that was convenient for her to use privately. She stated that no staff had offered her the use of a staff office or any other mechanism for private communication, and she was upset because she relied on telephone contact with her significant other, who had cancer and was unable to visit. Observations and staff interviews confirmed the lack of accessible, private telephone options for residents on South Hall. An observation on the 100 Hall revealed there was no cordless telephone available for resident use. The DON confirmed that the facility did not have a method to provide residents on South Hall with private communication without first making arrangements or an appointment to use a staff office, and that the cordless telephones in the facility did not have sufficient range to reach South Hall. The SSD confirmed there were no cordless telephones at the South Hall nurses’ station that could be taken to residents’ rooms and acknowledged that Resident #1’s cell phone had been broken and sent out for repair. The Administrator also confirmed that residents on South Hall did not have a method for private communication without prior arrangements and acknowledged that access to private communication is a guaranteed resident right.
Failure to Provide Adequate ADL Assistance for Personal Hygiene
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) to maintain personal hygiene for one resident who was dependent on staff for care. Facility policy on ADLs, revised March 2018, stated that residents unable to carry out ADLs independently would receive services necessary to maintain good grooming and personal and oral hygiene. Record review showed the resident was admitted with heart failure, chronic kidney disease, and hypertension, had a BIMS score of 12 indicating moderate cognitive impairment, was always incontinent of bowel and bladder, and required substantial/maximal assistance for personal hygiene and was dependent for toilet hygiene. A complainant reported that the resident had expressed difficulty getting staff to provide assistance with ADLs. During an observation and interview with the resident, accompanied by an LPN, the resident reported ongoing difficulty obtaining assistance with ADLs. The surveyor observed that the resident had ten long, dirty fingernails protruding 3.0 to 3.5 millimeters past the fingertips, with a black substance beneath all fingernails; the resident stated they needed cleaning and cutting and were too long. The LPN described the fingernails as too long and dirty, confirmed that nursing staff were responsible for checking fingernails daily during care and weekly during body audits, and acknowledged that staff were responsible for providing fingernail care as part of ADLs. The LPN also confirmed that long, dirty, unkempt fingernails had the potential to cause damage or scratches to the resident’s skin. The DON stated she was not aware of any complaints from the resident but confirmed her expectation that ADLs for residents dependent on staff for personal hygiene would be maintained and provided as needed, and that licensed nurses trimmed fingernails for some residents while any nursing staff could clean under fingernails. The Administrator confirmed that personal hygiene and grooming were part of resident ADLs and were expected to be provided for all dependent residents.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
