Lakeland Community Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Jackson, Mississippi.
- Location
- 3680 Lakeland Lane, Jackson, Mississippi 39216
- CMS Provider Number
- 255116
- Inspections on file
- 27
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Lakeland Community Care Center during CMS and state inspections, most recent first.
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.
Surveyors found that two residents’ rooms were not maintained in a clean, orderly, and homelike condition as required by facility policy. Observations included a urine collection device on a bathroom floor, cracked linoleum tiles, holes and missing sections of drywall and door frame, discolored and dusty baseboards, dark buildup on floors and exposed plumbing, and a dust-covered hand sanitizer dispenser with brown spots and streaks on nearby walls. Both residents, admitted with conditions including DM, HTN, and acute kidney failure and assessed as cognitively intact, reported dissatisfaction with the thoroughness of housekeeping and noted cluttered personal belongings and poor attention by staff to putting items away. The housekeeping supervisor confirmed that many of the observed residues should have been cleaned by housekeeping and that damaged surfaces required maintenance.
The facility failed to ensure that in-room meals were served hot and palatable for two residents who reported that their meals were usually cold or not hot enough to be enjoyable, despite a policy requiring staff to check that hot foods are hot. Both residents, who were cognitively intact and had diagnoses including DM and HTN (with one also having acute kidney failure), received meals on trays where insulated dome covers were used without the corresponding heat-keeper bases, and some dome covers did not fully cover the plates. Kitchen observation showed inconsistent and incomplete use of insulated components due to an insufficient supply, and dietary staff and the Administrator were unable to explain the improper use and lack of insulated bases for all in-room meal trays.
A resident who had recently undergone hip replacement surgery and required opioid pain management was discharged home without her prescribed as-needed Hydrocodone-Acetaminophen, despite facility policy and physician orders requiring all current medications to be sent with her. Staff interviews confirmed that the medication was not provided due to unclear instructions and lack of consultation with the physician, and the remaining medication was destroyed after discharge. The resident later reported not receiving her pain medication.
The facility failed to provide sufficient nursing staff on four days in January 2025, as revealed by observations, interviews, and record reviews. The absence of a staffing policy and frequent call-ins led to inadequate CNA coverage, particularly on weekends. An LPN confirmed that a resident's medication was left unattended due to insufficient staff, highlighting the impact on resident care.
A resident's room had torn and buckling linoleum flooring, creating a potential fall hazard. The resident, who was moderately cognitively impaired and at high risk for falls, had been living with this issue for several months. Despite complaints from the resident's sister and reports from staff, the Maintenance Director had not repaired the floor due to being the only maintenance staff. The Administrator was aware of the problem and had plans for repair but had not yet acted.
A dietary staff member failed to sanitize a thermometer properly between food temperature checks, using a paper towel instead of an alcohol pad, leading to cross-contamination. The Dietary Manager confirmed that this practice was against training protocols and could cause gastrointestinal issues for residents.
A facility failed to follow Enhanced Barrier Precautions for a resident with a PEG tube, as observed during two care instances where LPNs did not wear gowns. Despite facility policy and signage indicating the need for gowns during high-contact activities, the LPNs did not comply, putting the resident at risk. The resident had a diagnosis of Metabolic Encephalopathy and was moderately cognitively impaired.
A facility inaccurately coded an MDS assessment for a resident discharged to home instead of a hospital. The resident, admitted for muscle weakness, was intended to return home after skilled care. Despite physician orders for home discharge, the MDS indicated a hospital discharge. Interviews confirmed the error, highlighting the importance of accurate MDS coding.
A facility failed to develop a person-centered care plan for a resident with impaired vision. The resident had diagnoses including Paralytic Ptosis and was seen by an optometrist who ordered glasses. However, the care plan did not address these needs due to a lack of awareness and documentation among staff, including LPNs and the Administrator. The Nursing Supervisors were responsible for updating the care plan, but the necessary information was not included, resulting in a deficiency.
The facility failed to secure medications, leaving them accessible to unauthorized individuals. An LPN left a medicine cup with various medications unattended on a cognitively impaired resident's bedside table. Another resident, cognitively intact, was found with medication cups containing Nystatin Cream on the bedside table, provided by a weekend nurse for self-application. Both instances violated the facility's medication storage policy.
The facility failed to document that residents were informed of their rights regarding Advance Directives. Three residents with various diagnoses, including dementia and heart disease, had incomplete Advance Directive forms that were not initialed to confirm receipt of information. The Social Services Director and Administrator acknowledged the oversight, confirming the forms did not reflect the residents' receipt of information.
Two residents reported disrespectful and demanding behavior by an LPN during procedures and medication administration, causing them anxiety. Despite complaints, the facility's response was inadequate, as the LPN continued to work in the same area. Both residents were cognitively intact, and the facility's investigation attributed the issue to personality conflicts.
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.
Failure to Maintain Clean, Orderly, and Homelike Resident Rooms
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment as required by its own “Homelike Environment” policy, which states that residents are to be provided with a clean, sanitary, and orderly environment. During surveyor observations and interviews, one resident’s room contained a urine collection device on the bathroom floor, a hole in the drywall above the light, and six cracked linoleum tiles near the entrance. The resident reported being at the facility for therapy and expressed dissatisfaction with housekeeping services. The Housekeeping Supervisor acknowledged that blackish-brown discolored areas on the floor required stripping and scraping, confirmed that baseboards in both affected residents’ rooms were dust-covered, and stated that easily removable substances should have been cleaned by housekeeping, while missing plaster and broken tiles required maintenance. In another resident’s room, surveyors observed a three-inch piece of the bathroom door frame and the threshold between the room and bathroom missing, a dust-covered wall-mounted hand sanitizer dispenser, multiple brown pinpoint spots and streaks on the wall below the dispenser, discolored and dusty baseboards with residue that wiped off easily, and a floor area behind the door with brown to black discoloration in the corner. The exposed plumbing pipes under the bathroom sink were only partially covered with polyfoam and had a dark brown substance on them, and there was a six-inch by one-inch area of missing drywall in the bathroom. This resident, who was cognitively intact and admitted with diabetes and hypertension, stated that housekeepers came daily but did not do a thorough job, that she had limited ability to put belongings away, and that staff were not conscientious about putting her items away, resulting in clothing and other items scattered on all surfaces. Both residents involved were cognitively intact per their MDS BIMS scores, and the Administrator acknowledged awareness of housekeeping and maintenance needs in resident rooms.
Failure to Maintain Hot, Palatable Temperatures for In-Room Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to provide palatable food at an appetizing and safe temperature to residents receiving in-room meal service. Facility policy titled “Assisting the Resident with In-Room Meals” (revised 2013) directed staff to check that hot foods are hot. Two cognitively intact residents, both with diabetes and hypertension and one with additional acute kidney failure, reported that meals served in their rooms were usually cold or not hot enough to be enjoyable. One resident stated staff told her that her meals were not hot because she was the last served due to her room location, and the other resident reported that her meals were never served hot but that she continued to eat them without replacement or reheating. On a kitchen observation, the cook prepared meals while a dietary aide placed plates on trays and covered them with insulated dome covers but did not use the insulated heat-keeper bases/underliners. Nine of 25 meals had dome covers that did not fully cover the plates, leaving food not completely covered to conserve heat, including the meal for one of the affected residents. Six of 25 plates were covered only by heat-keeper bases instead of dome covers, again including a meal for one of the affected residents. During interviews, the dietary aide and dietary supervisor could not explain why heat-keeper bases were used instead of dome covers for some meals and acknowledged there were not enough heat-keeper bases for all residents receiving in-room meals. The Administrator stated she did not know why insulated bases were not being used and had not been informed of any shortage of insulated components.
Failure to Provide Discharge Medications to Resident
Penalty
Summary
The facility failed to ensure that a resident was discharged with all prescribed medications, specifically an as-needed opioid pain medication, as required by facility policy and physician orders. The resident, who had recently undergone hip replacement surgery and had diagnoses including end stage renal disease and acute postprocedural pain, was discharged home with home health care. Despite having a current physician order for Hydrocodone-Acetaminophen 5-325 mg to be taken as needed for pain, the medication was not sent home with the resident at discharge. Interviews with facility staff, including an LPN, the MDS nurse, the DON, and the Administrator, confirmed that the standard procedure was to send all current medications with the resident unless otherwise directed by the physician. The LPN responsible for the discharge did not send the pain medication, citing unclear instructions and without consulting the prescribing physician or the resident's primary healthcare provider. The MDS nurse and DON both confirmed that there were no orders to discontinue the medication and that the resident was expected to continue all current medications at home. Documentation reviewed included the resident's admission record, MDS, history and physical, physician orders, and discharge instructions, all of which indicated the ongoing need for pain management and continuation of prescribed medications. The controlled drug record showed that the remaining Hydrocodone-Acetaminophen tablets were destroyed after the resident's discharge, rather than being provided to the resident as required. The resident later contacted the facility to report that the pain medication had not been sent home.
Inadequate Staffing Leads to Deficiency
Penalty
Summary
The facility failed to ensure sufficient nursing staff to meet the needs of residents on four specific days in January 2025. The deficiency was identified through observations, staff interviews, and record reviews. The facility did not have a staffing policy in place, and anonymous complaints indicated that the 3-11 and 11-7 shifts were consistently short of Certified Nursing Assistants (CNAs). On one occasion, a single CNA was left to manage the Central Unit during the 3-11 shift. The Payroll Based Journal (PBJ) data for the 4th quarter showed a One Star Staffing Rating and excessively low weekend staffing, which corroborated the staffing issues. The Facility Assessment Tool indicated that the resident acuity and population required nine CNAs for the 3-11 shift and seven to eight CNAs for the 11-7 shift. However, the staffing grid revealed that on the days in question, the facility operated with fewer CNAs than required. Interviews with the LPN/Staffing Coordinator and the Administrator highlighted challenges in maintaining adequate staffing levels due to frequent call-ins and illnesses related to COVID-19. An LPN confirmed that a resident's medication was left unattended because there was insufficient staff to provide necessary care and encouragement, further illustrating the impact of inadequate staffing on resident care.
Failure to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to ensure a homelike environment for a resident, identified as Resident #5, due to the poor condition of the linoleum flooring in the resident's room. The flooring was torn and folded back under the resident's wheelchair and was also buckling under the bed. This condition was observed during a survey, and it was reported that the flooring had been in disrepair for several months. The resident's sister had complained to the nursing staff and the Administrator, expressing concerns about the flooring being a fall risk. The resident, who was moderately cognitively impaired with a BIMS score of eight, was at high risk for falls and transferred herself from bed to wheelchair without assistance. Interviews with facility staff, including a CNA, an LPN, and the Maintenance Director, confirmed that the flooring issue had been known for at least a month. The Maintenance Director acknowledged the potential fall hazard but had not repaired the floor due to being the sole maintenance staff. The Administrator was aware of the issue and had plans to install new tile but had not yet completed the repair. The Administrator expected CNAs to elevate the bed to prevent further damage to the flooring, but the bed required manual adjustment, complicating the process.
Improper Food Handling and Sanitation Practices
Penalty
Summary
The facility failed to ensure proper food handling and sanitation practices to prevent cross-contamination during a kitchen observation. Dietary staff member #2 was observed using a brown paper towel to clean a thermometer between checking food temperatures on the tray line, instead of using an alcohol pad as required. This improper practice was confirmed during an interview with the Dietary Manager, who stated that using a paper towel instead of an alcohol pad constitutes cross-contamination. Dietary staff had been trained to use alcohol swabs for this purpose. During a phone interview, the dietary staff member admitted to using a paper towel due to nervousness and acknowledged that this action could lead to cross-contamination and potential gastrointestinal issues for residents.
Failure to Follow Enhanced Barrier Precautions for Resident with PEG Tube
Penalty
Summary
The facility failed to ensure that Enhanced Barrier Precautions (EBP) were followed during care for a resident requiring high-contact precautions. Specifically, during two separate observations, Licensed Practical Nurses (LPNs) did not wear gowns while providing care to a resident with a percutaneous endoscopic gastrostomy (PEG) tube. The facility's policy, dated April 2024, mandates the use of gowns for residents with indwelling medical devices during high-contact care activities to prevent infection, especially for those at risk of being infected with multidrug-resistant organisms (MDROs). The resident involved, admitted in June 2024, had a diagnosis of Metabolic Encephalopathy and a moderately impaired cognitive status. Despite the presence of signage on the resident's door indicating the need for gloves and gowns during high-contact activities, such as PEG tube care, the LPNs failed to comply. Interviews with the LPNs and the Infection Preventionist confirmed the oversight and acknowledged the risk posed to the resident due to the lack of proper personal protective equipment (PPE) usage.
Inaccurate MDS Coding for Resident Discharge
Penalty
Summary
The facility failed to accurately code a Minimum Data Set (MDS) assessment for a resident who was discharged to home, not to a hospital as recorded. The resident, admitted with a diagnosis of muscle weakness, was intended to return home after a brief stay for skilled care. A review of the Discharge MDS with an Assessment Reference Date (ARD) indicated the resident was discharged to a short-term general hospital, contrary to the physician's telephone orders which specified discharge to home. Interviews with the Social Services Director and the MDS nurse confirmed the error, acknowledging that the MDS was incorrectly coded. The MDS nurse and the Administrator both recognized the importance of accurate MDS coding to reflect the care provided accurately.
Failure to Develop Person-Centered Care Plan for Impaired Vision
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident with impaired vision. The resident, admitted on 6/23/23, had diagnoses including Paralytic Ptosis of the left eyelid and was seen by an optometrist on 09/19/2024, who diagnosed him with Dry Eye Syndrome and ordered glasses. Despite these diagnoses and orders, the resident's care plan did not address his impaired vision. Interviews with various Licensed Practical Nurses (LPNs) revealed a lack of awareness regarding the resident's optometrist visit, diagnosis, and the need for glasses. The care plan remained generic due to the absence of documented information about the resident's vision impairment. The Administrator and LPNs were unaware of the resident's impaired vision and the optometrist's orders, as the eye examination documentation was not included in the medical records. The Nursing Supervisors were responsible for ensuring that such orders were incorporated into the care plan, with the Care Plan Nurse serving as a backup. However, the optometrist's report and the admission diagnosis were not addressed, leading to the deficiency in the resident's care plan.
Medication Security Lapses in Facility
Penalty
Summary
The facility failed to ensure medications were secured and inaccessible to unauthorized residents and staff during the survey. On one occasion, an LPN left a medicine cup containing Vitamin C, Multivitamin, Levothyroxine, Metoprolol, and Pravastatin unattended on a resident's bedside table. The resident, who had a moderately impaired cognition with a BIMS score of eight, was lying flat in bed without staff supervision. The LPN admitted to leaving the medication because the resident was slow to take her medication and acknowledged the risk of choking or another resident taking the medication. In another instance, a resident with a BIMS score of 15, indicating cognitive intactness, was found with two medication dispensing cups containing an unidentified cream on the bedside table. The resident stated that the weekend nurse provided the cream for self-application as needed for itching. Upon review, the cream was identified as Nystatin External Cream. An LPN confirmed that medications should not be left at the bedside, indicating a lapse in following the facility's medication storage policy.
Failure to Document Resident Rights on Advance Directives
Penalty
Summary
The facility failed to maintain complete and accurate medical records by not documenting that residents were informed of their rights regarding Advance Directives. This deficiency was identified in the records of three residents who were admitted with various diagnoses, including Unspecified Dementia, Atherosclerotic Heart Disease, and Vascular Dementia. The review of the Resident Rights/Advance Directive forms revealed that these forms were not initialed by the residents or their representatives, indicating that they had not been informed about formulating an Advance Directive. During interviews, the Social Services Director (SSD) confirmed her responsibility for completing the Advance Directive forms and acknowledged that they were incomplete. The Administrator also confirmed that the forms failed to reflect the residents' receipt of information related to Advance Directives. The responsibility for ensuring that all information related to the residents' choices was documented was attributed to the SSD.
Failure to Ensure Respectful Treatment of Residents
Penalty
Summary
The facility failed to ensure that nursing staff treated residents with respect and dignity during procedures and medication administration, affecting two residents. Resident #5 reported that an LPN was disrespectful and demanding when collecting a urine sample, a behavior she had experienced frequently. Despite her repeated complaints, the facility only transferred her medications to another nurse after the incident. The resident expressed anxiety about seeing the LPN, who continued to work in her hall. The facility's investigation concluded that the allegations of abuse were not valid, attributing the issue to a personality conflict. Resident #6 also reported similar issues with the same LPN, describing her as rude and demanding during medication administration and medical procedures. The resident had previously complained to the Administrator, which led to temporary improvement in the LPN's behavior. However, the LPN resumed her previous conduct, causing the resident anxiety. The resident's representative noted that the facility should have taken more decisive action, such as moving the LPN to another hall. Both residents were cognitively intact, as indicated by their BIMS scores. The facility's response to the complaints was inadequate, as the LPN continued to work in the same area despite the residents' discomfort and anxiety. The Administrator acknowledged the complaints but did not initially reassign the LPN or the residents' medications, which contributed to the ongoing issues.
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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