Ms Care Center Of Alcorn County, Inc-snf
Inspection history, citations, penalties and survey trends for this long-term care facility in Corinth, Mississippi.
- Location
- 3701 Joanne Drive, Corinth, Mississippi 38834
- CMS Provider Number
- 255110
- Inspections on file
- 24
- Latest survey
- April 1, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Ms Care Center Of Alcorn County, Inc-snf during CMS and state inspections, most recent first.
A resident with a history of a healed Stage 4 sacral pressure injury had the wound reopen after the air mattress was found set to static instead of alternating pressure. The resident said the pump setting was not right, an LPN confirmed the mattress had become firm and lost pressure redistribution, and the DON and Treatment Nurse verified the wound reopened after the control box was found incorrectly set.
Failure to obtain informed consent for psychotropic meds: The facility initiated psychotropic medications for multiple residents without signed consent forms from the resident or representative. Records showed no psychotropic consent policy, and the DON stated the facility had not been doing consent forms. The affected residents had diagnoses including schizoaffective disorder, depression, anxiety, dementia, and bipolar disorder, with several showing moderate to severe cognitive impairment on BIMS.
Improper Labeling and Dating of Refrigerated Food: During a kitchen tour, multiple items in two reach-in coolers were observed without open dates or expiration dates, including sliced tomatoes, cheese, pasta salad, sauces, eggs, juices, milk, and sweet tea. The DM confirmed that open food items should not be stored without dating and that facility policy requires all opened foods to be labeled with an open date for safety and organization.
Pest Control Failure in Food and Nutrition Services: Multiple flies were observed in the kitchen prep and cook area, and a cockroach was seen crawling on the floor in the Dietary Manager's office during a kitchen tour. The DM confirmed that the presence of flies and roaches was unsanitary and should not be present in food prep or food storage areas. Facility policy stated that a pest management program is used to prevent pests from entering the food and nutrition service department.
A resident’s urinary catheter drainage bag was observed hanging visibly on the side of the bed without a privacy bag, and the QA Nurse confirmed it was exposed and a dignity concern. The resident had multiple medical diagnoses, including a stage 4 sacral pressure ulcer, HF, COPD, and CKD, and had moderate cognitive impairment per BIMS.
Failure to maintain privacy during wound care: A resident with a stage 3 L heel pressure injury and other skin issues received wound treatment and a brief-down skin check without the window blind being closed. The Wound Nurse performed the care while the window was visible from the courtyard, and later confirmed the blind was not closed even though the resident was cognitively intact.
Failure to provide ordered nutritional supplement: A resident with CCD/NAS orders and significant recent weight loss did not receive Super Pudding with meals because the item was on back order for weeks. Staff confirmed the supplement was missing from the meal tray, no alternative was provided, and communication about the back order was not relayed to the RD. The resident had CKD, had recently started dialysis, and was severely cognitively impaired.
Failure to verify Trilogy ventilator settings and oxygen connection. A resident with acute respiratory failure with hypercapnia and COPD exacerbation was observed extremely SOB with rapid respirations while on 3 L O2 by NC, and the Trilogy ventilator beside the bed had no oxygen enrichment line attached. Record review showed an order to use the Trilogy at HS, but no physician-ordered settings or order to ensure oxygen was bled into the device. Staff and the DON confirmed the settings were not verified, and the RT stated the facility should have had ventilator settings in place and that the oxygen adapter line was not connected.
An LPN observed that insulin pens on a medication cart for two residents were in use but not dated when opened. Facility policy and in-service materials stated insulin should be dated when opened and discarded after 28 days. The LPN stated undated insulin could not be verified as safe to administer, and the DON stated nursing staff should ensure insulin on medication carts is labeled with an open date.
Failure to use EBP during high-contact care and to keep Foley catheter tubing secured and off the floor. A resident with a suprapubic catheter received catheter care from CNAs without EBP despite an order for it; another resident with a PEG tube had medication administration performed by an LPN who forgot to wear a gown; and a third resident with a Foley catheter was repeatedly observed with tubing unsecured and touching or dragging on the floor, which the DON acknowledged as an infection control concern.
A resident with significant medical needs experienced acute respiratory distress and was transferred to the hospital without the resident representative being notified, due to miscommunication between two LPNs. The representative only learned of the transfer upon visiting the facility, despite facility policy requiring immediate notification of such changes.
A resident identified as a wandering risk exited a facility unnoticed due to a door malfunction and inadequate staff response to an alarm. The resident was later found asleep in a car miles away. The incident highlighted failures in supervision and policy implementation regarding elopement risks.
A resident in a LTC facility reported abuse and neglect by a night shift nurse, who was rude, refused pain medication, and mishandled the resident's call light. The resident, with a history of fractures and pain, felt unsafe and expressed a desire to leave. Witnesses confirmed the nurse's misconduct, including yelling and unjustified withholding of medication.
A resident in an LTC facility reported feeling unsafe and not receiving proper care during the night shift. The resident's responsible party noted rude behavior from a nurse, and the resident expressed a desire to leave due to untreated pain and misconduct. Staff interviews confirmed these issues, but the incident was not reported to the State Agency as required.
A resident with multiple fractures did not receive prescribed pain medication due to an LPN's decision to withhold it over concerns about constipation. The resident, who was cognitively intact, experienced untreated pain, as confirmed by the DON and documented in the MAR. The MDS Coordinator noted potential impacts on therapy and daily activities.
The facility failed to implement pain management interventions for a resident with fractures, resulting in unaddressed pain due to a lapse in medication administration. Additionally, the facility did not develop an individualized care plan for a resident with PTSD, omitting specific triggers that caused distress. These deficiencies highlight a lack of adherence to pain management and trauma-informed care policies, impacting the residents' well-being.
A facility failed to ensure proper food temperature checks and documentation, leading to a deficiency in food safety. A resident reported receiving cold soup, which was confirmed during an observation. The dietary staff admitted to not checking temperatures and falsely documenting them. The Dietary Manager acknowledged the issue, and the Administrator emphasized the importance of temperature checks for food safety.
The facility failed to resolve resident grievances about cold food, as reported by several residents during Resident Council meetings. Despite complaints being documented and communicated to department heads, the issue persisted over several months. The Dietary Manager attempted to address the problem by instructing staff to warm plates and announcing when meal trays were ready, but residents continued to experience cold meals.
A facility failed to provide a homelike environment due to cold water in a shower room, affecting residents' comfort. A resident reported the issue to the Administrator, and CNAs confirmed multiple complaints. Maintenance inaccurately assessed water temperatures by checking the sink instead of the shower faucet, leading to a finding of 88 degrees in the shower. The Administrator acknowledged the issue after being informed by maintenance.
A facility failed to submit a PASRR status change for a resident with a new diagnosis of Schizoaffective Disorder. The resident, initially assessed without requiring a Level II PASRR, received the new diagnosis, but the Social Services staff was not informed, leading to the oversight. Interviews with the DON and Administrator confirmed the failure to update the PASRR documentation.
A facility failed to provide trauma-informed care for a resident with PTSD, who experienced significant trauma during the Vietnam War. Despite the diagnosis, the facility did not conduct a trauma assessment or identify triggers, and the resident did not receive specialized mental health services. The facility's Cultural Assessment packet, which includes trauma care needs, was implemented after the resident's admission, leading to a lack of appropriate care.
Air Mattress Set Incorrectly After Sacral Pressure Injury Healed
Penalty
Summary
The facility failed to maintain interventions intended to prevent recurrence of a pressure injury for one resident with a history of a Stage 4 sacral pressure injury. The resident was readmitted with diagnoses including a Stage 4 sacral pressure ulcer, heart failure, COPD, and chronic kidney disease, and the MDS showed a BIMS score of 10, indicating moderate cognitive impairment. Facility policy directed staff to inspect skin during care and to use pressure-relieving devices and alternative support surfaces as needed for Stage 3, 4, unstageable, or deep tissue injuries on the trunk. The resident’s sacral wound had been documented as healed, but later reopened and was again assessed as a Stage 4 sacral wound. The resident stated the pump button on the air mattress was not set correctly and reported being told to make sure staff did not bump the pump and that it stayed on. An LPN confirmed the air mattress had been mistakenly set to static mode, making it firm and eliminating alternating pressure, and stated this likely contributed to friction during repositioning and pulling up in bed. The DON confirmed the wound had healed previously and then reopened after the mattress was found set to static, and the Treatment Nurse reported the control box was observed set to static at a weight setting of 260 when the resident complained of buttock discomfort.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent from the resident or resident representative before initiating psychotropic medications for five residents reviewed for unnecessary medications. Record review showed the facility did not have a psychotropic consent policy, and the Administrator provided a signed statement dated 03/31/26 stating the facility did not currently have a Psychotropic Consent Policy. For each of the five residents, the record review identified psychotropic medication orders and a lack of signed consent forms prior to medication initiation. Resident #4 had an order for Zyprexa for schizoaffective disorder and a BIMS score indicating the resident was rarely/never understood. Resident #6 had orders for Olanzapine and Zoloft for affective mood disorder and depression, with a BIMS score of 10 showing moderate cognitive impairment. Resident #10 had orders for Trazodone and Risperidone for depression, and the DON stated during interview that the facility had not been doing consent forms and had only recently discovered they should have been. Resident #12 had orders for Quetiapine, Seroquel XR, and Risperdal for affective disorder, bipolar disorder, and anxiety, with a BIMS score of 11 indicating moderate cognitive impairment. Resident #92 had orders for Alprazolam, Seroquel, Sertraline, and Trazodone for anxiety, dementia-related behavioral symptoms, depression, and insomnia, with a BIMS score of 7 indicating moderate cognitive impairment.
Improper Labeling and Dating of Refrigerated Food
Penalty
Summary
The facility failed to label and store food properly in the kitchen during a survey observation. Review of the facility policy titled "Storage of Refrigerated Food" revised 11/23 showed that all opened foods are to be labeled with the common name of the food and the date stored and/or use-by date. During the initial kitchen tour with the Dietary Manager, several items in reach-in cooler number one were observed without dates indicating when they were opened or when they expired, including sliced tomatoes, sliced cheese in a clear container, a five-gallon container of pasta salad, a one-gallon container of sweet and sour sauce, an uncovered four-pound container of sweet cornbread, 12 boiled eggs, one-gallon containers of liquid seasoning sauce, sweet pickle relish, BBQ sauce, jalapeno peppers, and apple cider vinegar. In reach-in cooler number two, several additional items were also present without open dates or expiration dates, including 46-ounce containers of prune juice, grape juice, and tomato juice, one-half gallon of buttermilk, two one-gallon jugs of whole milk, and one one-gallon jug of sweet tea. The Dietary Manager confirmed that open food items should not be stored without an open date and that facility policy requires all open food items to be labeled with an open date for safety and organization.
Pest Control Failure in Food and Nutrition Services
Penalty
Summary
The facility failed to maintain effective pest control management by preventing pests from entering the food and nutrition service department. During the initial kitchen tour with the Dietary Manager, multiple flies were observed randomly flying around in the kitchen prep and cook area, and a cockroach was seen crawling on the floor in the Dietary Manager's office. The facility policy stated that a pest management program is used to prevent pests from entering the food and nutrition service department and to implement measures to eliminate any pest infestations. During interview, the Dietary Manager confirmed that the presence of pests, including flies and roaches, was unsanitary and should not be present in food prep or food storage areas.
Failure to Maintain Privacy for Catheter Drainage Bag
Penalty
Summary
The facility failed to maintain Resident #3’s right to dignity by not providing privacy for the resident’s urinary catheter drainage bag. During an observation, the drainage bag was noted hanging on the lower left side of the bed with approximately 100 cc of yellow urine and was not placed in a privacy bag, making it clearly visible to anyone entering the room. When the Quality Assurance Nurse responded to the resident’s call light, the nurse confirmed that the drainage bag was not in a privacy bag and acknowledged that its exposure was a dignity concern. Resident #3 was re-admitted on 1/31/26 with diagnoses including stage 4 pressure ulcer of the sacral region, heart failure, COPD, and chronic kidney disease, and the MDS dated 3/9/26 showed a BIMS score of 10, indicating moderate cognitive impairment.
Failure to Maintain Privacy During Wound Care
Penalty
Summary
The facility failed to ensure resident privacy during wound care for one of four observed care opportunities. Facility policy stated that residents must be examined and treated in a manner that maintains bodily privacy, using a closed door and/or drawn cubicle curtain to maximize privacy while care is rendered. Resident #90 had orders for daily wound care to a stage 3 pressure injury on the left heel and had diagnoses including a nondisplaced zone I fracture of the sacrum, a stage 3 pressure ulcer of the left heel, and a stage 1 pressure ulcer of the left buttock. During observation of wound care, the Wound Nurse performed treatment to the left heel and pulled the resident’s brief down to assess the buttocks without shutting the window blind. The window was visible from the courtyard, where another resident and one staff member were outside at the time. The Wound Nurse later confirmed she did not close the blind before providing care and stated it should have been closed for the resident’s privacy. The resident’s MDS showed a BIMS score of 15, indicating the resident was cognitively intact.
Failure to Provide Ordered Nutritional Supplement
Penalty
Summary
The facility failed to ensure that Resident #8 received an ordered nutritional supplement, Super Pudding, with lunch and supper meals. During a dining observation on 3/30/2026, the supplement was not present on the resident’s lunch tray, which otherwise included barbecue chicken, sweet peas, potato salad, garlic bread, peach cobbler, and 4 ounces of apple juice. The resident had diet orders for a Controlled Carb Diet, No Added Salt, and Super Pudding to lunch and supper meals, and the physician order for the supplement had been received and entered on 2/27/2026. Facility staff confirmed that the supplement was unavailable because it was on back order for about three weeks, and the resident was not provided an alternative. The Dietary Manager stated she notified the QA nurse that the supplement was on back order, while the QA nurse stated she did not communicate that information to the RD. Resident #8 had a history of weight loss, with weights documented as 160 lbs on 1/1/2026, 155 lbs on 2/1/2026, 145 lbs on 2/10/2026, and 148 lbs on 3/1/2026. The RD noted on 3/24/2026 that the resident triggered for significant weight loss of 4.5% in 30 days and that the resident had recently started dialysis. The resident’s admission record listed generalized muscle weakness and chronic kidney disease, and the MDS showed a BIMS score of 04, indicating severe cognitive impairment.
Failure to Verify Trilogy Ventilator Settings and Oxygen Connection
Penalty
Summary
The facility failed to ensure physician-ordered settings and proper oxygen integration for a Trilogy ventilator for one resident. The resident was observed in bed with the head of the bed elevated and extremely short of breath with rapid respirations while receiving oxygen at 3 liters by nasal cannula. At the same time, the Trilogy ventilator was sitting beside the bed without an oxygen enrichment line connected to the device, and a later observation again found the Trilogy machine without an oxygen enrichment line attached. Record review showed an order to apply the Trilogy at bedtime, but there were no physician-ordered settings and no order directing staff to ensure oxygen was connected to the machine at the ordered rate. The resident also had an order for oxygen at 3 LPM by nasal cannula every shift. Staff interviews confirmed the resident’s Trilogy settings were not in the orders, the machine had come from home pre-set by the medical equipment provider, and staff had not verified the programmed settings for accuracy. The DON stated there was no process in place to ensure the resident was receiving the correct settings because the machine came pre-set. The respiratory therapist later confirmed the facility should have ventilator settings in place to verify the physician-prescribed parameters and that oxygen needed to be bled into the device at 2-4 liters per the physician order; she observed the oxygen adapter line was not connected when she assessed the machine.
Undated Insulin Pens on Medication Cart
Penalty
Summary
The facility failed to ensure insulins were stored in accordance with manufacturer guidelines to maintain safety and effectiveness for one of two medication carts observed. On the 300 hall medication cart, an observation with an LPN found that Resident #2's Lantus SoloStar and Resident #4's Basagalar KwikPen and Tresiva FlexTouch were in use but were not dated when opened. Facility policy stated insulin pens should be disposed of after 28 days, and the facility's insulin expiration calculator and in-service materials also stated that insulin vials should be dated when opened and discarded 28 days after initial opening. During interview, the LPN stated all insulin vials or pens should be dated when opened and that there would be no way to determine if the insulin was still safe to administer. The DON stated that all insulin stored on medication carts should be checked by nursing staff to ensure they are labeled with an open date.
Failure to Use EBP and Maintain Catheter Equipment
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program to prevent the spread of infection, as evidenced by failure to use Enhanced Barrier Precautions (EBP) during high-contact care and failure to maintain urinary catheter equipment in a manner to prevent contamination. Facility policy stated that EBP was to be used for residents with feeding tubes, high-contact resident care activities, and device care or use, and that indwelling catheter tubing must be secured, kept off the floor, and positioned to prevent contamination. For Resident #2, who had a suprapubic catheter and diagnoses including urinary tract infection and retention of urine, CNA #3 and CNA #4 were observed providing catheter care without using EBP, despite an order for EBP related to the suprapubic catheter. For Resident #13, who had a PEG tube and diagnoses including cerebral infarction, an LPN was observed administering PEG medication without wearing a gown for EBP and stated she had forgotten. For Resident #77, who had an indwelling Foley catheter and diagnoses including retention of urine and acute kidney failure, the catheter tubing was repeatedly observed unsecured and touching or dragging on the floor while the resident sat in a wheelchair and at a dining room table; the DON confirmed the tubing was lying on the floor and identified it as an infection control concern.
Failure to Notify Resident Representative of Hospital Transfer
Penalty
Summary
The facility failed to notify a resident's representative of a significant change in the resident's physical condition and the subsequent transfer to the hospital. According to the facility's policy, staff are required to immediately inform the resident, consult with the resident's physician, and notify the resident representative when there is a significant change in the resident's status or a decision to transfer the resident. In this case, the resident experienced acute respiratory distress with extremely low oxygen saturation, prompting staff to contact the physician, who ordered a hospital transfer. Interviews with staff revealed that two LPNs were involved in the emergency response and transfer process. One LPN was responsible for the resident's care and called 911 and the emergency room, while the other assisted with preparing paperwork for the transfer. Both LPNs assumed the other had notified the resident's representative, resulting in no notification being made. The Director of Nursing confirmed that the notification was not completed and that this was due to miscommunication between the two nurses. The resident's representative discovered the resident's absence when visiting the facility and was informed by staff that the resident had been hospitalized for several days. Documentation in the resident's records and a grievance report confirmed that the representative was not notified of the change in condition or the transfer. The resident had a history of cerebrovascular disease, hemiplegia, and acute respiratory failure, and was unable to communicate effectively, making representative notification especially important.
Resident Elopement Due to Inadequate Supervision and Door Malfunction
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident, identified as a wandering risk, from exiting the facility unnoticed and unsupervised. The resident left the facility through the front door early in the morning and was later found asleep in the back seat of a car approximately eight miles away. The incident was discovered when the resident was not found in his room during breakfast tray delivery, prompting a search and notification of local authorities. The resident was last seen by a CNA who assisted him to a sitting area, where he usually stayed until breakfast. However, the resident exited the facility through the front door, which did not latch properly after a phlebotomist entered. A LPN was seen on camera entering the alarm code on the door shortly after the resident's exit but did not investigate the cause of the alarm, assuming it was triggered by the phlebotomist. The resident was found without injuries after being transported to a local hospital for evaluation. The facility's policy on elopement and wandering residents was not effectively implemented, as the resident's elopement risk was underestimated, and staff failed to respond appropriately to the door alarm, leading to the resident's unsupervised departure.
Removal Plan
- Immediate action started.
- Resident #1 was noticed to be missing when his dining room tray was delivered to the hall by Certified Nursing Assistant (CNA).
- A Code W was initiated by Unit Manager, Registered Nurse (RN). All staff searching for resident and one hundred percent audit was completed to ensure all other residents were present.
- Assistant Director of Nursing (ADON) notified Director of Nursing (DON).
- Director of Nursing (DON) notified Administrator.
- Local Police Department, Local Fire and Rescue, and Attorney General Investigation Team were notified resident missing by Quality Assurance Licensed Practical Nurse (LPN).
- Resident #1 House shoe was located by Housekeeper #1 in parking lot of local crisis center.
- Resident Responsible Party and Resident Physician Family Nurse Practitioner (FNP) notified by Assistant Director of Nursing (ADON).
- Review of security cameras by Minimum Data Set (MDS) Registered Nurse (RN) saw Resident #1 exiting facility via front door.
- Janitor #1 was assigned to monitor the front door and the Maintenance Supervisor contacted Locksmith to evaluate door closure mechanism.
- Facility was notified by the Dietary Manager while watching security footage at the Crisis Center that the resident was seen getting into the back of an employee vehicle. Crisis Center then notified the employee to have someone check in the car and notify police. Resident was asleep in the back seat.
- Local police department went to the crisis center's staff member's residence and called Emergency Medical Services (EMS) for transport to Local Hospital for evaluation. Resident #1 was evaluated and noted to have no injury or signs of distress.
- Resident #1 arrived at local emergency room and Infection Control, Registered Nurse (RN) was sent to supervise Resident #1 until return to facility.
- Locksmith present and working on front door to replace door closures.
- Resident #1 returned to facility, Body Audit completed revealing no injuries. Visual checks initiated every 15 minutes for total of four hours, every 30 minutes for total of 4 hours, and every 1 hour for eight hours to total 24 hours. Resident #1 will be monitored every hour indefinitely.
- Resident #1 Wander Guard Bracelet was checked and was determined to be functioning. All residents with Wander Guards were checked and found to be functional. They will be checked each shift by nurse for functional status.
- Resident Elopement Assessment and Care Plan were updated to include actual elopement on Resident #1.
- DON, Assistant DON, Minimum Data Set Registered Nurse (RN), and Admissions Registered Nurse (RN) did one hundred percent Elopement Assessment on all residents. Care Plans for residents with Elopement Risk were updated to include visual checks every hour.
- Visual Monitoring will be monitored by the nurse each shift, any discrepancies will be reported to the Quality Assurance Nurse who will report findings to the Quality Assurance Committee monthly for three months, then quarterly.
- An Ad Hoc Emergency Quality Assurance and Improvement Committee meeting was held related to resident elopement to conduct a root cause analysis and Policy and Procedure for changes.
- Director of Nursing, Quality Assurance Nurse, and Staff Development Nurse initiated in-services for all staff related to Elopement and Wandering Prevention, Response to Alarms, and following Care Plans. No employee will be allowed to return to work without training.
- An Elopement Drill was completed and will continue to be conducted daily for 3 days on each shift, then weekly for three weeks, then monthly. Social Services will report findings to the Quality Assurance Committee monthly.
- License Practical Nurse (LPN) #1 was suspended pending termination.
Resident Abuse and Neglect Due to Staff Misconduct
Penalty
Summary
The facility failed to protect a resident from abuse and neglect, as evidenced by multiple incidents involving a night shift nurse. The resident, who was cognitively intact and had a history of multiple fractures and unspecified pain, reported that the nurse was rude, refused to administer his pain medication, and threw his call light on the floor. The resident expressed fear and a desire to leave the facility due to feeling unsafe and not receiving proper care. Witness statements corroborated the resident's claims, with reports of the nurse yelling and refusing to provide pain medication due to the resident's constipation. The Director of Nursing (DON) confirmed the resident's complaints and found documentation supporting the resident's claims of untreated pain. The DON's investigation revealed that the nurse admitted to withholding medication without a valid reason. Although the DON could not substantiate all allegations, such as the call light being ignored, the overall findings indicated a failure to ensure the resident's right to be free from abuse and neglect.
Failure to Report Alleged Abuse and Neglect
Penalty
Summary
The facility failed to identify and report an allegation of abuse and neglect to the proper authorities within the required timeframes for one resident. The incident involved a resident who expressed feeling unsafe and not receiving proper care during the night shift. The resident's responsible party reported that the night shift nurse was rude and hateful, and the resident expressed a desire to discharge home due to feeling unsafe. The investigation revealed that the resident's pain was left untreated, and staff interviews provided examples of misconduct toward the resident. Further documentation indicated that the resident reported staff being rude, refusing to provide medications, and throwing the call light on the floor, refusing to assist the resident onto the bedside commode. A witness statement from a Physical Therapy Assistant noted the resident's emotional distress and fear, while a Licensed Practical Nurse reported hearing another nurse yelling at the resident and refusing to administer pain medication. Despite these findings, the incident was not reported to the State Agency as required, as the Director of Nursing and the Administrator did not initially identify it as an allegation of abuse and neglect.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to provide appropriate pain management for Resident A, who had multiple fractures and unspecified pain, as per the physician's orders. The resident was admitted with significant injuries, including fractures to the maxillary, orbital wall, ribs, and radius, and was experiencing pain that limited daily activities. Despite having an active order for Hydrocodone-Acetaminophen to be administered every six hours as needed, there was a lapse in administering the medication from the afternoon of one day until the following morning. This gap in medication administration was documented in the Medication Administration Record (MAR) and was corroborated by the resident's complaints and a grievance report filed by the Social Services/Grievance Official. The deficiency was further highlighted by a witness statement from an LPN who overheard another LPN stating that the medication was withheld due to the resident's constipation. The Director of Nursing (DON) confirmed that the nurse's decision to withhold medication was not justified and acknowledged that the resident's pain was left untreated. The Minimum Data Set (MDS) Coordinator noted that such failures could lead to unrelieved pain and impact the resident's ability to participate in therapy and daily activities. The resident, who was cognitively intact, confirmed the lack of pain management, which was also reported by his son to the DON.
Failure in Pain Management and PTSD Care Planning
Penalty
Summary
The facility failed to implement pain management care plan interventions for Resident A, who had a history of fractures and was at risk for altered comfort. Despite having an active order for Hydrocodone-Acetaminophen to be administered every six hours as needed for pain, there was a significant gap in medication administration. On 10/20/24, Resident A received a dose at 1:34 PM, but no further doses were documented until 9:58 AM the following day. This lapse occurred despite Resident A's complaints of pain and requests for medication, which were ignored by the staff. The Director of Nursing confirmed that the nurse withheld the medication due to the resident's constipation, which was not in accordance with the care plan. Additionally, the facility failed to develop a care plan with individualized interventions for Resident #64, who had a diagnosis of PTSD. The care plan lacked specific triggers related to the resident's PTSD, despite the resident's disclosure of triggers such as loud noises that caused significant distress. The Director of Nursing and the MDS Coordinator acknowledged that a PTSD assessment was not conducted, and the care plan did not provide staff with the necessary information to manage the resident's mental health needs effectively. Both deficiencies highlight a failure to adhere to the facility's policies on pain management and trauma-informed care. The lack of proper documentation and individualized care planning resulted in unmet needs for both residents, impacting their overall well-being and quality of care. The facility's staff did not follow established protocols, leading to unaddressed pain and psychological distress for the residents involved.
Failure to Ensure Proper Food Temperature Documentation
Penalty
Summary
The facility failed to ensure that food temperatures were adequately checked and documented, leading to a deficiency in food safety standards. During a kitchen observation, it was found that the temperature of chicken noodle soup served to a resident was significantly below the required 135 degrees Fahrenheit, measuring only 80 degrees. The dietary staff admitted to not checking the food temperatures for breakfast and lunch, and the temperature records were falsely documented, indicating that temperatures were checked when they were not. The Dietary Manager confirmed that the temperature records were pre-filled for meals that had not yet occurred, and acknowledged the importance of checking food temperatures to prevent foodborne illnesses. A resident, who is cognitively intact with a BIMS score of 15, reported receiving cold soup on multiple occasions. The resident's complaint was corroborated during a dining room observation when the soup was returned to the kitchen for being cold. The facility's Administrator was unaware of the issue and had not received complaints about cold food, but emphasized the importance of checking food temperatures to ensure food quality and safety. The deficiency highlights a lapse in the facility's adherence to its policy on maintaining proper food temperatures, as well as a failure in oversight by the dietary staff and management.
Facility Fails to Resolve Resident Grievances on Cold Food
Penalty
Summary
The facility failed to address and resolve resident grievances regarding cold food and lack of hot water, as reported by six residents during Resident Council meetings. The residents consistently voiced concerns about receiving cold meals during breakfast, lunch, and supper, both in their rooms and in the dining room. Despite these complaints being documented in multiple Resident Council meetings, the issue remained unresolved. The facility's policy mandates prompt efforts to resolve grievances, but the residents reported that the problem persisted over several months. Interviews with staff revealed that the Social Services representative was aware of the complaints and had communicated them to the relevant department heads, including the Dietary Manager. However, the Administrator was unaware of the ongoing concerns. The Dietary Manager acknowledged the issue and had attempted to address it by instructing staff to warm plates and announcing when meal trays were ready. Despite these efforts, the residents continued to experience cold food, indicating that the facility's actions were insufficient to resolve the grievances effectively.
Cold Water in Shower Room Fails to Ensure Homelike Environment
Penalty
Summary
The facility failed to ensure a homelike environment by not providing adequate hot water in the 300-hall shower room, as observed during a survey. Resident interviews revealed that the water in the shower room was often cold, with Resident #28 specifically mentioning a cold shower experience and reporting it to the Administrator. Certified Nurse Aides (CNAs) confirmed multiple resident complaints about the cold water, and although maintenance was aware of the issue, they consistently checked the water temperature at the sink rather than the shower faucet, leading to inaccurate assessments of the water temperature. During an observation, the water temperature in the middle shower stall was found to be 88 degrees, which was too cold for a shower, while the sink water temperature was 106 degrees. Maintenance workers admitted they had only been checking the sink, assuming it provided an accurate reading. The Administrator acknowledged the problem after being informed by the maintenance department and recognized the failure to provide a warm shower as not promoting a homelike environment. Resident #28, who is cognitively intact, had to receive a bed bath due to the cold water issue.
Failure to Submit PASRR Status Change for New Mental Illness Diagnosis
Penalty
Summary
The facility failed to submit a status change for a resident with a new mental illness diagnosis to the Preadmission Screening and Resident Review (PASRR) program. This deficiency was identified during a review of records and staff interviews. The resident in question, admitted to the facility on a previous date, was initially assessed on 8/23/23 and did not require a Level II PASRR at that time. However, on 1/29/24, the resident received a new diagnosis of Schizoaffective Disorder, which necessitated a status change submission to the PASRR system. The Social Services staff member responsible for submitting such changes was not informed of the new diagnosis, resulting in the failure to submit the required status change. Interviews with facility staff, including the Social Services representative, the Director of Nursing (DON), and the Administrator, confirmed the oversight. The DON emphasized the importance of following the PASRR process to ensure proper placement and service provision for residents. The Administrator also acknowledged the facility's failure to submit the PASRR status change for the resident's new mental health diagnosis. The resident's records indicated a history of cerebral infarction and a recent diagnosis of Schizoaffective Disorder, highlighting the need for updated PASRR documentation to reflect the resident's current mental health status.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care and services for a resident diagnosed with Post Traumatic Stress Disorder (PTSD). The resident, who served in the Vietnam War, experienced significant trauma during his service, which included being left for dead and witnessing the death of fellow soldiers. Despite his PTSD diagnosis, the facility did not conduct a trauma assessment or identify triggers that could affect his mental health. The resident reported that loud noises, such as thunder, were triggers for him, causing significant distress. Interviews with facility staff, including the Social Service representative and the Director of Nursing, revealed that the facility did not assess the resident for trauma care needs upon admission in 2022. The facility's Cultural Assessment packet, which includes trauma care needs, was only implemented in 2023, after the resident's admission. Consequently, the resident did not receive specialized mental health services from the facility's mental health care provider, despite his PTSD diagnosis. The facility's failure to assess and address the resident's PTSD and triggers was confirmed by both the Director of Nursing and the Administrator.
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A resident with advanced dementia and severe cognitive impairment sustained a bruised left eye and facial bruising after being struck by a CNA. The CNA initially claimed the injury occurred accidentally while pushing the resident to a dining table and denied hitting the resident, but an LPN and another CNA reported that the resident stated she had hit the CNA and was hit back in the eye, demonstrating a slapping motion. Nursing documentation described left orbital ecchymosis, bruising along the bridge of the nose and cheek, tenderness, minimal edema, and the resident’s complaint of soreness, confirming a significant injury resulting from the physical abuse.
The facility failed to protect residents’ right to a dignified and comfortable environment when it did not effectively manage one cognitively impaired resident’s ongoing nighttime yelling, which repeatedly disrupted the sleep of two cognitively intact residents. Staff, including a CNA, the DON, and the Administrator, were aware that this resident, diagnosed with dementia and psychosis, frequently yelled and screamed at night while often sleeping during the day. Progress notes documented nighttime hollering, and interviews confirmed that the disruptive behavior persisted over time, interfering with other residents’ ability to rest.
Surveyors found that the facility failed to protect two residents’ rights to dignity and privacy during routine care. One resident, with moderate cognitive impairment and dependent for toilet hygiene, was observed receiving incontinence care while uncovered, with the room door open and the privacy curtain only partially drawn, allowing visibility into the hallway despite facility policy requiring full privacy. Another resident, dependent for eating and with hemiplegia after a stroke, was assisted with lunch by a CNA who stood over the resident instead of sitting at eye level as required by the facility’s feeding skills checklist. Staff interviews, including with CNAs, an LPN, the DON, and the Administrator, confirmed that existing policies and in-service training directed staff to provide privacy during incontinence care and to sit beside residents when assisting with meals to ensure dignified care.
A resident with epilepsy, skin infection, an upper arm wound, gastrostomy status, and moderate cognitive impairment was observed twice resting in bed with a lunch tray while the call light was not within reach—once on the floor under the bed and once hanging behind the mattress, out of sight. The resident reported being able to use the call light but not knowing where it was. Staff, including CNAs, an LPN, the DON, and the Administrator, stated that call lights are expected to be left within residents’ reach and that training and competencies address this requirement, but there was no specific written policy on call light placement.
A resident with moderate cognitive impairment, dependent for toilet hygiene and with multiple medical conditions, was observed receiving incontinent care in which a CNA removed a urine-soaked brief, changed the bed sheet, and applied a clean brief without performing any required perineal cleansing of the front or back. Facility policy and the peri-care skills checklist specified that male residents must have the perineal area, including the penis, scrotum, and inner thighs, washed, rinsed, and dried during incontinent care. The CNA later acknowledged having been trained and competency-checked on this procedure and knowing cleansing was required. Other staff, including a CNA supervisor, an LPN, the DON, and the Administrator, confirmed that proper incontinent care includes full perineal cleansing in addition to brief changes, establishing that the observed omission did not follow facility policy or professional standards intended to prevent UTIs.
Surveyors found that staff failed to follow infection control practices during PEG tube and wound care. Two residents with PEG tubes had sites with visible brown, crusted or yellowish drainage that had not been cleaned for several days, despite physician orders for daily cleansing and, when indicated, dressings. In another case, a CNA provided peri-care for stool and then assisted with a stage IV sacral pressure ulcer dressing change without changing gloves or performing hand hygiene, contrary to facility policy and staff expectations for aseptic technique.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment when a resident’s room contained odorous soiled linens left on the floor and later placed on furniture with clean clothing, and the bed was made with torn linens exposing the mattress. Other residents reported that housekeeping did not clean under beds, and multiple large dead roaches were repeatedly observed under several beds, with one resident stating he often disposed of dead roaches himself. Residents also reported refusing to use the north shower room due to dirty clothing, feces, and residue on shower chairs and floors; an observation confirmed the presence of soiled clothing, a soiled brief, and unidentified substances on the shower chair and floor, despite staff acknowledging that CNAs were expected to clean and sanitize the shower room after each use.
The facility failed to maintain an effective pest control program, as evidenced by repeated observations of roaches and other insects in multiple resident rooms and common areas. Surveyors found gnats and dead roaches under beds, while several residents reported seeing roaches on ceilings, walls, and floors, including roaches falling onto them at night and having to remove dead roaches themselves. A family member reported bringing her own roach spray due to concerns about roaches in a loved one’s room. During a Resident Council meeting, roaches were seen crawling across the floor, and residents stated that roaches were commonly observed throughout the building. Although the contracted pest control provider reported monthly service focused mainly on entry points and exterior areas and facility staff described processes for reporting pests, the persistent roach activity showed the program was not effectively preventing or controlling pests.
A resident with multiple chronic conditions, who relied on phone contact with a seriously ill significant other, lost access to private communication after her personal cell phone was broken and sent out for repair. Facility policy guarantees residents access to a telephone and private communication, but there was no cordless phone available on the relevant hall, and staff, including the DON, SSD, and Administrator, confirmed there was no convenient method for residents on that hall to make private calls without arranging to use a staff office. This resulted in the resident having no readily available, private telephone option.
A resident with heart failure, chronic kidney disease, hypertension, moderate cognitive impairment, and total dependence on staff for personal and toilet hygiene reported difficulty obtaining assistance with ADLs. Observation revealed the resident had ten long, dirty fingernails extending several millimeters beyond the fingertips with black material underneath, and the resident stated they needed cleaning and cutting. An LPN confirmed the nails were too long and dirty, acknowledged that nursing staff were responsible for daily and weekly fingernail checks and for providing fingernail care as part of ADLs, and noted that such nails could cause skin damage or scratches. The DON and Administrator both confirmed that personal hygiene and grooming are part of ADLs and are expected to be provided for all residents dependent on staff.
Failure to Protect Cognitively Impaired Resident From Physical Abuse by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse, resulting in the resident being struck in the eye by a CNA. Facility records show that a CNA reported to an LPN that the resident had a bruised left eye and initially stated the injury may have occurred while pushing the resident to the dining table due to the resident’s short, stooped posture. The CNA also reported that the resident used a racial slur toward her and that she verbally responded but denied striking the resident. However, subsequent interviews and the facility’s investigation determined that the resident’s injury was not caused by accidental contact with the dining table. Interviews with staff revealed conflicting accounts that led to the conclusion that the resident had been hit. An LPN stated that the resident reported being hit in the eye by the CNA and that another CNA heard a commotion and later observed bruising to the resident’s left eye. When this second CNA asked what happened, the resident reported that she hit the CNA and was hit back in the eye, while making a motion consistent with a slap. The LPN confirmed that the resident gave a similar account to her, indicating that the CNA had physically struck the resident. The resident involved was admitted to the Memory Care Unit with diagnoses including Alzheimer’s disease, cognitive communication deficit, and unspecified dementia with behavioral disturbance, and had a BIMS score of 5 indicating severe cognitive impairment. A nursing progress note documented an acute follow-up assessment of left orbital ecchymosis, describing a dark red circular bruise to the left eye region, dark purple bruising along the lateral bridge of the nose extending to the superior left cheek, tenderness on palpation, minimal edema, and the resident’s complaint that the area was sore. Due to advanced Alzheimer’s disease, the resident was unable to reliably express additional symptoms, but the documented physical findings supported that the resident sustained a significant injury to the eye area as a result of being struck by the CNA.
Failure to Protect Residents’ Right to Rest Due to Unmanaged Nighttime Yelling
Penalty
Summary
The deficiency involves the facility’s failure to ensure a dignified and comfortable environment by not effectively addressing ongoing disruptive nighttime behaviors of one resident that interfered with other residents’ ability to rest. Resident #1, admitted with diagnoses including Psychosis and Dementia and a BIMS score of 4 indicating severely impaired cognition, had documented episodes of hollering and yelling during nighttime hours, as noted in progress notes on 3/12/26 and 3/13/26. Interviews with cognitively intact residents, Resident #2 and Resident #3 (both with BIMS scores of 15), revealed that they frequently experienced disrupted sleep due to Resident #1 yelling loudly at night, while the environment was generally quiet during the day. Staff interviews confirmed awareness of the pattern of behavior. CNA #1, who worked both day and night shifts, reported that Resident #1 frequently yelled and screamed at intervals throughout the night and was generally quiet and often slept during the day, with staff assisting the resident out of bed into a geri-chair during both day and nighttime hours. The DON acknowledged the facility was aware of Resident #1’s increased nighttime yelling and extended daytime rest, attributing it to the resident’s Dementia and Psychosis, and stated that interventions such as monitoring, repositioning, offering care, and attempts at redirection had not stopped the behaviors. The Administrator also confirmed awareness of concerns that nighttime noise from Resident #1 affected other residents’ ability to rest. Despite this awareness and ongoing complaints from other residents, the disruptive nighttime yelling continued, resulting in a failure to uphold residents’ rights to a dignified existence and a comfortable environment.
Failure to Ensure Privacy and Dignified Care During Incontinence Care and Feeding
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were treated with dignity and provided privacy during care, as required by resident rights policies and skills checklists. The facility’s Nursing Facility Resident Rights policy guaranteed residents the right to be treated with dignity, courtesy, and respect, and to have privacy during personal care. Facility skills checklists for feeding and peri/incontinent care specified that staff should sit facing residents at eye level when feeding and provide privacy by drawing curtains and closing doors during incontinence care. For Resident #2, surveyors observed a CNA providing incontinent care without closing the resident’s room door and with the privacy curtain only partially drawn. From the surveyor’s position at the bottom right corner of the bed, it was possible to see into the hallway while the resident was uncovered and exposed. Resident #2’s records showed admission with diagnoses including epilepsy, infection of the skin and subcutaneous tissue, an open wound of the left upper arm, and gastrostomy status. A recent MDS assessment documented a BIMS score of 11, indicating moderate cognitive impairment, and that the resident was dependent for toilet hygiene. The CNA later confirmed awareness that incontinence care required provision of privacy and that she had been trained and competency-checked on this requirement. For Resident #3, surveyors observed a CNA assisting the resident with eating while standing over the resident rather than sitting beside her, contrary to the facility’s feeding skills checklist and training. The DON intervened during the observation and instructed the CNA that staff were to sit next to residents while assisting with eating. The CNA stated she had forgotten to sit beside the resident. Resident #3’s records showed recent admission with diagnoses of cerebral infarction (stroke), anemia, and hemiplegia and hemiparesis affecting the right dominant side, and a baseline care plan indicating the resident was dependent for eating. Other staff interviews, including with a CNA supervisor, an LPN, the DON, and the Administrator, confirmed that staff were trained at least monthly on residents’ rights, respectful and dignified care, provision of privacy during incontinence care, and the expectation that staff sit beside residents when assisting with eating.
Failure to Maintain Accessible Call Light for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was maintained within reach as required by the facility’s feeding skills checklist. The skills checklist for feeding a resident specifies that staff must leave the call light within the resident’s reach after feeding. For Resident #2, surveyors observed on two separate occasions that the call light was not accessible. On one observation, the resident was awake in bed with a lunch tray on the overbed table, and the call light was found lying on the floor under the head of the bed. The resident stated he could use his call light but did not know where it was. On a subsequent observation, Resident #2 was again in bed with a lunch tray in front of him, and the call light was hanging behind the mattress at the head of the bed, out of his sight and reach. The resident again stated he could use the call light but did not know where it was. Record review showed the resident had epilepsy, an infection of the skin and subcutaneous tissue, an open wound of the left upper arm, gastrostomy status, and a BIMS score of 11 indicating moderate cognitive impairment. Staff interviews with CNAs, an LPN, the DON, and the Administrator confirmed that call lights were expected to be within residents’ reach and answered timely, and that staff had received in-service training and competency checks on leaving call lights within reach. The Administrator also confirmed there was no specific written policy regarding call light placement.
Failure to Provide Required Perineal Cleansing During Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to provide incontinent care in accordance with its own peri-care policy and professional standards of practice for a male resident who was dependent for toilet hygiene. The facility’s written policy for peri/incontinent care for male residents, revised in January 2023, required cleansing of the perineal area starting at the urethra and working outward, including washing and rinsing the penis, scrotum, inner thighs, and perineal area front and back, followed by thorough drying. Record review showed the resident had diagnoses including epilepsy, infection of the skin and subcutaneous tissue, an open wound of the left upper arm, and gastrostomy status, and a Quarterly MDS with a BIMS score of 11 indicating moderate cognitive impairment, with the resident assessed as dependent for toilet hygiene. On the observed date and time, CNA #1 provided incontinent care to this resident by removing a wet urine-soaked brief, changing the fitted sheet, and applying a clean, dry brief without cleansing the resident’s perineal area, front or back, contrary to facility policy. During a subsequent interview, CNA #1 acknowledged she had received in-service training and competency check-offs on peri-care and knew she was supposed to cleanse the perineal area but did not do so, stating she was nervous. Additional interviews with CNA #2 (CNA supervisor and scheduler), an LPN, the DON, and the Administrator confirmed that staff were trained using the Peri Care–Incontinent Care Skills Checklist and that proper incontinent care includes cleansing the perineal area, front and back, in addition to changing the brief. The failure to perform the required cleansing during incontinent care constituted the cited deficiency related to prevention of urinary tract infections.
Failure to Maintain Infection Control Practices During PEG Tube and Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program by not maintaining aseptic technique and not providing ordered dressing changes for residents with PEG tubes and a sacral pressure injury. Facility policies on infection control and clean dressing changes required wound care to be provided in a manner that decreases the potential for infection and cross-contamination, including removal of soiled dressings with gloves, discarding gloves, performing hand hygiene, and donning clean gloves before continuing care. The peri-care audit tool also required glove removal, hand hygiene, and re-gloving after peri-care. These standards were not followed during multiple observed care episodes. For one resident with a PEG tube and diagnoses including Alzheimer’s disease, functional quadriplegia, and gastrostomy status, surveyors observed the PEG tube site without a dressing and with a yellowish-brown substance beneath and around the external skin disk extending about one-fourth inch onto surrounding skin. A CNA and an LPN both confirmed there was no dressing in place and acknowledged the drainage at the site. The LPN stated PEG tube site care should be completed daily and as needed for increased drainage and acknowledged that, with no dressing and the amount of drainage present, there was no way to tell when the site was last cleaned. Record review showed a physician order, effective several months prior, for daily cleansing of the PEG tube stoma with normal saline, patting dry, and applying a dry drain dressing to avoid skin breakdown. For another resident with severe protein-calorie malnutrition and gastrostomy status, the PEG tube site was observed with thick brown, crusted substance beneath the external skin disk extending approximately one-half to three-fourths of an inch to the surrounding area. The resident reported the site had not been cleaned in about three days and later stated they might have to clean it themselves. Follow-up observations confirmed the site remained unclean with visible drainage, and an LPN and the DON both confirmed the presence of thick, brown drainage and that the site had not been cleaned in several days, despite an order for daily cleansing with soap and water, rinsing, patting dry, and leaving open to air or applying a dry dressing if drainage was present. In a separate observation involving a resident with a stage IV sacral pressure ulcer and severe cognitive impairment, a CNA provided peri-care for stool soiling, then immediately assisted with wound care using the same gloves worn during peri-care, without performing hand hygiene or changing gloves. The CNA, treatment nurse, DON, and ADON all acknowledged that hand hygiene and glove change should have occurred between peri-care and wound care and that this represented an infection control concern.
Failure to Maintain Clean Resident Rooms and Shower Facilities
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by its Resident Rights & Quality of Life Policy. For one resident, surveyors observed a bag of odorous soiled linens resting on the floor of the room, and the resident’s bed was made with a bedspread that had a football-sized hole exposing the mattress. The resident, who was cognitively intact with a BIMS score of 14 and had Type 2 Diabetes Mellitus, reported that it was not unusual for bags of soiled linens to be left on the floor and for bedding to be damaged. A CNA confirmed that soiled linens were commonly left in bags on the floor after morning care and that torn bedding should not be used, and later placed the bag of soiled linens on the resident’s furniture where his clean clothing was hanging. The resident remained upset the following day, and a dead roach was observed under his bed near the headboard. Additional deficiencies were identified in other resident rooms. One resident with End Stage Renal Disease and a severely impaired cognition (BIMS score of 5) reported that housekeeping did not clean under the bed; surveyors observed three large dead roaches under the bed, which remained there the following day. When the Housekeeping Supervisor later observed the room, five dead roaches were present under the bed, and he stated the area should not have been in that condition. Another resident, with a diffuse traumatic brain injury and a moderately impaired cognition (BIMS score of 10), reported frequently picking up and disposing of dead roaches himself because staff did not remove them, and a large dead roach was observed under his bed. The facility also failed to maintain a clean and sanitary north shower room. During a Resident Council interview, multiple cognitively intact and moderately impaired residents reported refusing to use the shower room due to cleanliness concerns, including observations of dirty clothing, feces, and residue on shower chairs and floors. A housekeeper stated that while she cleaned the shower rooms multiple times a day, CNAs were responsible for cleaning and sanitizing the shower room after each use and that she had observed occasions when CNAs failed to do so. A subsequent observation of the north shower room revealed soiled clothing, including a soiled brief, on a shower chair, a yellow fluid-like substance on the floor and shower chair, and a white powdery substance on the floor, with no staff present. The Social Services Assistant, DON, and Administrator each acknowledged that staff were expected to clean and sanitize the shower room after each use.
Ongoing Roach Activity Demonstrates Ineffective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program as required by its pest control policy dated 9/1/2014, which states the center will maintain an ongoing program to keep the building free of insects and rodents. Surveyors observed multiple instances of roach and insect activity in resident rooms and common areas. In one cognitively intact resident’s room, gnats were seen flying and a dead roach was later found under the bed near the headboard. Another resident’s room contained three large dead roaches under the bed on two consecutive days; this resident reported that roaches were regularly seen in the room, especially at night, crawling on the ceiling and falling onto him and his roommate, and that staff had been notified but he had not seen staff respond to assess or treat the issue. A third resident reported seeing roaches on the ceiling and under the bed and stated he often removed dead roaches himself because staff did not; a large dead roach was observed under his bed. A family member of another resident reported feeling it was necessary to bring her own roach spray due to concerns about roaches in the resident’s room and stated she was told she could not keep the spray in the room, expressing concern that the roach problem needed to be addressed. During a Resident Council meeting, two large roaches were observed crawling across the floor, and residents reported that roaches were commonly seen in rooms and common areas, including on walls, ceilings, and floors, particularly at night. The contracted pest control provider reported he provides monthly services, focusing on different areas each visit, primarily treating entry points and exterior areas, and stated he had not personally observed roaches and received only occasional complaints. Facility leadership, including the housekeeping supervisor, DON, and Maintenance Director, described expectations that staff report pest sightings and that pest control services are available monthly and as needed, but the ongoing presence of roaches and dead insects in resident rooms and common areas demonstrated that the pest control program was not effectively preventing or controlling pests.
Failure to Ensure Resident Access to Private Telephone Communication
Penalty
Summary
The facility failed to ensure a resident’s right to reasonable access to and privacy in the use of a telephone for communication. Facility policy on Resident Rights, revised December 2016, states that residents are guaranteed access to a telephone, mail, and email, and the ability to communicate in person and by mail, email, and telephone with privacy. Resident #1 was admitted on 12/18/24 with diagnoses including Sjogren syndrome, rheumatoid arthritis, chronic kidney disease, and morbid obesity. During an interview, the resident reported that she had dropped and broken her personal cellular telephone, which she had used for private communication, and that the facility did not have any telephone that was convenient for her to use privately. She stated that no staff had offered her the use of a staff office or any other mechanism for private communication, and she was upset because she relied on telephone contact with her significant other, who had cancer and was unable to visit. Observations and staff interviews confirmed the lack of accessible, private telephone options for residents on South Hall. An observation on the 100 Hall revealed there was no cordless telephone available for resident use. The DON confirmed that the facility did not have a method to provide residents on South Hall with private communication without first making arrangements or an appointment to use a staff office, and that the cordless telephones in the facility did not have sufficient range to reach South Hall. The SSD confirmed there were no cordless telephones at the South Hall nurses’ station that could be taken to residents’ rooms and acknowledged that Resident #1’s cell phone had been broken and sent out for repair. The Administrator also confirmed that residents on South Hall did not have a method for private communication without prior arrangements and acknowledged that access to private communication is a guaranteed resident right.
Failure to Provide Adequate ADL Assistance for Personal Hygiene
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) to maintain personal hygiene for one resident who was dependent on staff for care. Facility policy on ADLs, revised March 2018, stated that residents unable to carry out ADLs independently would receive services necessary to maintain good grooming and personal and oral hygiene. Record review showed the resident was admitted with heart failure, chronic kidney disease, and hypertension, had a BIMS score of 12 indicating moderate cognitive impairment, was always incontinent of bowel and bladder, and required substantial/maximal assistance for personal hygiene and was dependent for toilet hygiene. A complainant reported that the resident had expressed difficulty getting staff to provide assistance with ADLs. During an observation and interview with the resident, accompanied by an LPN, the resident reported ongoing difficulty obtaining assistance with ADLs. The surveyor observed that the resident had ten long, dirty fingernails protruding 3.0 to 3.5 millimeters past the fingertips, with a black substance beneath all fingernails; the resident stated they needed cleaning and cutting and were too long. The LPN described the fingernails as too long and dirty, confirmed that nursing staff were responsible for checking fingernails daily during care and weekly during body audits, and acknowledged that staff were responsible for providing fingernail care as part of ADLs. The LPN also confirmed that long, dirty, unkempt fingernails had the potential to cause damage or scratches to the resident’s skin. The DON stated she was not aware of any complaints from the resident but confirmed her expectation that ADLs for residents dependent on staff for personal hygiene would be maintained and provided as needed, and that licensed nurses trimmed fingernails for some residents while any nursing staff could clean under fingernails. The Administrator confirmed that personal hygiene and grooming were part of resident ADLs and were expected to be provided for all dependent residents.
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