Pleasant Hills Community Living Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Jackson, Mississippi.
- Location
- 1600 Raymond Rd, Jackson, Mississippi 39204
- CMS Provider Number
- 255112
- Inspections on file
- 26
- Latest survey
- February 23, 2026
- Citations (last 12 mo.)
- 2 (1 serious)
Citation history
Health deficiencies cited at Pleasant Hills Community Living Center during CMS and state inspections, most recent first.
A resident with COPD, heart failure, rheumatoid arthritis, moderate cognitive impairment (BIMS 9), and wheelchair dependence was transported by facility staff to an outside medical appointment when the wheelchair was not properly secured in the facility van. CNAs reported using the van’s securement system but did not use any checklist to verify correct application; during transit they heard a noise and found the resident on the van floor with the wheelchair on its side and the seatbelt no longer in place. The resident reported hitting the head and having head pain. The facility’s investigation and QAPI review determined that the wheelchair straps had not been appropriately placed to firmly secure the chair, while the maintenance review found the securement equipment itself intact and functioning. The resident was evaluated in a hospital ED for fall and head injury and treated with an over-the-counter analgesic after imaging showed no new diagnoses.
A resident with moderate cognitive impairment and a history of depression and falls exited the facility unsupervised after staff failed to intervene or follow elopement prevention procedures. The resident was outside for over 20 minutes and found 0.4 miles away, highlighting a lapse in supervision and adherence to facility policy.
Two residents with a history of aggression toward each other were involved in multiple physical altercations, resulting in injury and pain requiring medication. Despite staff awareness and attempts at monitoring and room changes, the residents continued to seek each other out, and effective interventions such as one-on-one supervision were not implemented. The facility did not ensure a safe environment free from abuse, as required by policy.
A resident with severe cognitive impairment and an indwelling urinary catheter was observed with the catheter collection bag visible from the hallway, as the privacy cover was left unsnapped and failed to conceal the bag or its contents. The facility's policy required the use of a privacy bag to preserve dignity, but this was not followed, as confirmed by the DON.
The facility discontinued the use of disposable premoistened cleansing cloths for several residents with wounds or fragile skin, despite previously informing residents and staff that these would be provided for those with such needs. Multiple residents and their families reported dissatisfaction with the alternative products, describing them as rough, inadequate, and leading to postponed or interrupted care. Medical records confirmed that the affected residents had significant medical conditions and required daily wound care, yet the facility did not supply the preferred cleansing cloths.
Two residents dependent on wheelchairs experienced discomfort and safety concerns due to damaged or unrepaired wheelchair armrests, while other residents did not receive timely personal hygiene care because of a lack of clean linens and inadequate cleansing supplies. Staff reported that care was postponed or interrupted, and residents and families expressed dissatisfaction with the quality and timeliness of care provided.
A facility did not report an allegation of resident-on-resident physical abuse to the State Agency within the required timeframe, despite staff witnessing and internally investigating the incident. Multiple staff, including an LPN, RN, and the Administrator, were aware of the event, but the Administrator chose not to report it due to ongoing incidents between the two residents and a denial from the alleged victim. Both residents had relevant medical histories and varying cognitive status, and the facility did not implement additional supervision at the time.
Two residents were observed with excessively long and dirty fingernails, and one with long toenails, despite expressing a desire for nail care. Both had medical conditions requiring assistance, and staff confirmed that nail care was part of ADL responsibilities and that supplies were available, but the care was not provided as required.
A resident with multiple diagnoses, including muscle weakness and altered mental status, experienced a fall that was documented in progress notes, but staff failed to complete an incident report, conduct follow-up monitoring, or provide required documentation. Interviews with LPN, staffing coordinator, and DON revealed lack of awareness or recall of the incident, and the administrator was unable to locate any related documentation, despite facility policy requiring assessment and documentation after falls.
A resident with no cognitive impairment was found to have two vials of Ipratropium-Albuterol Inhalation Solution, one opened and one unopened, left unsecured on the overbed table in their room. Facility policy requires medications to be stored securely and only allows bedside storage with a prescriber's written order, which was not present. The DON and Administrator were unaware of the unsecured storage, and there was no individual medication storage cabinet in the room.
The facility did not include required information about staffing levels or the number of mechanical lifts needed in its facility-wide assessment, resulting in insufficient resources to meet resident care needs. Staff scheduled shifts based on PPD without considering resident acuity or unit-specific needs, and only one full-body lift and one sit-to-stand lift were available, causing delays in care for dependent residents, including those with morbid obesity.
The facility failed to secure medications, leaving a medication cart and treatment cart unlocked and unattended, and medications were left at a resident's bedside. An LPN admitted to leaving a medication cart unlocked, and a wound care nurse left a treatment cart unattended. A resident was found with medications left on their bedside table, which the LPN confirmed was against procedure. The resident was cognitively intact with a history of cerebral infarction.
The facility failed to respect resident dignity and privacy in two incidents. A CNA attempted to check a resident for incontinence in the hallway against his wishes, despite the resident's request to delay care. The resident, diagnosed with paraplegia, resisted the CNA's actions. In another case, a resident's urinary catheter drainage bag was left uncovered, exposing the urine. Both an LPN and the DON confirmed that such bags should be kept in privacy covers. The resident had a diagnosis of neuromuscular dysfunction of the bladder.
A facility failed to label and date enteral feeding bags for a resident receiving nutrition via a feeding tube. Observations showed that the bags were not labeled with the formula name, date, or time. Interviews with staff revealed a lack of accountability between shifts, with an LPN and the DON indicating it was the night nurses' responsibility to label the bags, which was not done.
A resident with Type 2 Diabetes Mellitus had a change in physician's orders from HumaLog KwikPen with sliding scale coverage to weekly accuchecks. The care plan was not updated to reflect this change, as the care plan nurse responsible was on vacation. The LPN and DON confirmed the oversight, which could lead to confusion in care. Facility policy mandates care plan revisions with order changes, but this was not followed.
A facility failed to conduct a safety smoking assessment for a resident, violating its policy to ensure a safe environment for smokers. The resident, who has been at the facility since 2013 and is cognitively intact, had not been reassessed for smoking safety since 2021. This oversight was confirmed by interviews with the resident, an LPN, and the DON, who acknowledged the lapse in following the facility's policy.
A facility failed to secure the indwelling catheter tubing for a resident with neuromuscular dysfunction of the bladder, as observed during a survey. Despite a physician's order to check and replace the urinary catheter leg strap every shift, the resident did not have a leg strap in place. The facility's policy requires securing catheters to prevent infections, but staff did not adhere to this procedure, as confirmed by the CNA, LPN, and DON.
The facility failed to ensure that residents were treated and spoken to in a dignified and respectful manner. Multiple interviews and record reviews revealed that an LPN routinely spoke to residents in a loud, rude, and aggressive manner, despite having received multiple warnings and additional training. The residents involved had varying degrees of cognitive function, with one being cognitively intact and the other showing no cognitive impairment.
A resident, who was cognitively intact and not identified as an elopement risk, managed to kick open an entrance door and exit the facility unnoticed. The resident was found by the police approximately 12 miles away after being unsupervised for about six to eight hours. The facility's failure to secure the entrance door and provide adequate supervision led to the incident.
The facility failed to treat residents with dignity and respect by not consistently ensuring that call lights were answered in a timely manner. Multiple residents reported waiting for extended periods, sometimes over two hours, for assistance, leaving them wet and soiled. The issue was confirmed by the Ombudsman and acknowledged by the facility's staff, who had conducted multiple in-services to address the problem.
The facility failed to obtain informed consent for the use of bed rails for seven residents. Observations and medical record reviews revealed that bed rails were in use without signed consent forms, which was confirmed by interviews with facility staff, including the Administrator and DON.
Failure to Properly Secure Wheelchair During Van Transport Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to properly secure a resident’s wheelchair in the facility van, resulting in a fall during transport. The facility’s accident/incident policy stated that all persons involved in an incident or accident, or suspected to have had one, are to be evaluated, treated as indicated, and monitored. For one resident who depended on a wheelchair for mobility, the incident report documented that while en route to a medical appointment, the resident fell backwards in the wheelchair and hit the back of the head, causing a small hematoma. The facility’s investigation concluded that although the resident was strapped in, the transportation assistant failed to ensure that the wheelchair straps were appropriately placed to firmly secure the chair, which allowed the chair to roll backwards. The QAPI committee’s review identified the primary cause of the fall as the resident’s wheelchair not being properly secured with appropriate straps to maintain a stable and secure position during transportation. CNA #1 reported that she used four hooks to secure the wheelchair frame to the van’s securement system and that the wheelchair was attached to the floor. During transport, she heard a noise, looked back, and saw the resident on the van floor with the wheelchair turned on its side and the seatbelt no longer secured around the resident. CNA #1 stated that the resident reported hitting her head and having head pain. CNA #2, who was driving, similarly reported hearing a noise, then observing the resident on the floor with the wheelchair on its side, and confirmed that no checklist was used to verify correct securement of the wheelchair. The Administrator stated she was notified shortly after the incident that the resident’s wheelchair had fallen over in the van and that the resident had hit her head and complained of head pain. The Maintenance Supervisor later inspected the van’s resident securement system and found all components intact and functioning correctly, indicating that the issue was not equipment failure but how the securement system was used. The resident’s records showed admission with diagnoses including COPD, heart failure, and rheumatoid arthritis, and a significant change MDS with a BIMS score of 9, indicating moderate cognitive impairment, and a need for a wheelchair for mobility. The hospital After Visit Summary documented that the resident was evaluated in the emergency department for a fall and head injury, with imaging showing no new diagnoses, and treatment with an over-the-counter analgesic.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment and a history of depression, repeated falls, and chronic atrial fibrillation was able to exit the facility unsupervised. The resident was last seen by staff at 10:37 AM and subsequently left the building behind a hospice nurse, with no staff intervening to prevent the exit. The resident was observed by a physical therapist assistant (PTA) leaving the facility, but the PTA assumed the resident was accompanied by staff and did not verify this or intervene. The resident continued out of the facility and was not stopped or redirected by any staff members, despite facility policies requiring supervision and intervention for residents at risk of elopement. The resident was outside and unsupervised for approximately 22 minutes, during which time she traveled 0.4 miles away from the facility, down a busy four-lane street, and was eventually found in the parking lot of a local funeral home. The resident was dressed in a sweatshirt and jeans, and the temperature was 51 degrees Fahrenheit. Interviews with staff revealed that there was a lack of immediate response to the resident's absence, and the missing resident procedure was not initiated promptly. Staff failed to maintain awareness of the resident's movements near the exit, and the facility's wandering and missing resident procedures were not followed as required. The facility's policy required that residents at risk for elopement be identified, have preventative plans of care implemented, and receive visual supervision as necessary. In this incident, the resident was not identified as being at risk for elopement at the time, and staff did not provide the required supervision or intervention. The failure to follow established procedures and to provide adequate supervision resulted in the resident being placed in a situation likely to cause serious injury, harm, impairment, or death.
Removal Plan
- Initiated a search within the building and outside the parameters for Resident #9 upon notification of elopement.
- Administrator checked Resident #9's room and the front entrance.
- Social Service Director (SSD) and Physical Therapy Assistant (PTA) assisted in searching outside.
- Located Resident #9 in front of the funeral home, 0.4 miles from the facility.
- Ensured Resident #9 was safe and uninjured.
- SSD called Resident #9's Resident Representative (RR) and informed her of the incident.
- Printed census for North and South unit and completed a head count to ensure all residents were accounted for.
- Completed a body audit on Resident #9 by RN with no injuries noted.
- Reported the incident to the State Agency.
- Maintenance completed an audit on all doors and windows to ensure proper functioning.
- On-call Nurse Practitioner (NP) notified and new order for in-house psych evaluation given.
- Medical Director, Medical Doctor (MD), and NP #2 notified by Administrator of the incident.
- All staff in-services began on Elopement/Unsafe wandering plan and the Emergency Procedure - Missing Resident and Abuse and Neglect; completed by Assistant Director of Nursing (ADON).
- Conducted an Elopement Drill by Maintenance Director, completed on all shifts and to be continued weekly for four weeks and monthly for three months.
- Held an emergency Quality Assurance Performance Improvement (QAPI) meeting with IDT members to discuss the incident, actions to be taken, and further interventions.
- Reviewed policy with QAPI committee; no recommendations for change.
- Added Resident #9 to the wander book and provided a wander guard.
- Person-centered in-services to be completed with staff whenever any new residents are identified as an elopement risk.
- Elopement drill on all shifts and one elopement drill per week on alternating shifts for four weeks, then monthly for three months.
- Head count by census.
- Maintenance quality check on all doors and windows.
- SSD to complete 100% audits on all wanderers, update wander book, update care plans, in-service on wander book location, conduct interview with resident for any psychosocial harm.
- Updated Medication Administration Record (MAR) with hourly visual monitoring for Nursing by RN.
- Point of Care (POC) updated for hourly visual tasks for CNAs to mark complete by MDS Nurse.
- SSD conducted interview with resident to assess psychosocial harm.
- Placed Wander Guard bracelet on Resident #9's left wrist.
- Care plans updated by SSD.
- 100% audit done on all wanderers by SSD and Wander Book updated with photos and face sheets.
- 100% audit done by SSD on all Wander Guard bracelets to ensure appropriate functional ability.
- Maintenance Director to perform elopement drills on all shifts, continue for four weeks and monthly for three months, and bring results before the QAPI committee each month for review and recommendations.
- Any issues to be addressed immediately by the Administrator and the DON.
- Incident reported to the Attorney General's Office by Administrator.
Failure to Prevent Repeated Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from repeated physical abuse by another resident, resulting in injury. Multiple incidents of resident-to-resident aggression occurred between two residents, both of whom were cognitively intact according to their Brief Interview for Mental Status (BIMS) scores. Despite ongoing abusive interactions, including physical altercations such as hitting, slapping, and use of objects to inflict harm, the facility did not implement effective interventions to prevent further abuse. Staff were aware of the ongoing relationship and history of aggression between the two residents, but hourly monitoring and room changes did not prevent the incidents, as the residents continued to seek each other out. Documentation and interviews revealed that staff, including CNAs, LPNs, and the Social Services Director, were aware of multiple incidents over several months. These included physical assaults resulting in visible injuries such as periorbital edema and redness to the eye, which required pain medication. The facility's policy required the prevention of abuse and the provision of a safe environment, but staff did not escalate supervision or consider one-on-one monitoring, even after repeated events. There was also a lack of consistent documentation for all incidents, and some staff could not recall if incident reports were completed. The residents involved had significant medical histories, including hemiplegia, diabetes, chronic kidney disease, and heart failure. Both residents had been referred to psychiatric and psychosocial services, and discharge planning was underway for one resident. However, these actions did not prevent further abuse prior to the most recent incident. The facility's failure to implement effective measures to separate or supervise the residents resulted in continued physical harm and did not uphold the residents' right to be free from abuse.
Failure to Maintain Resident Dignity by Not Concealing Catheter Bag
Penalty
Summary
The facility failed to uphold a resident's right to respectful and dignified care by not properly applying a privacy cover to an indwelling urinary catheter collection bag. According to the facility's urinary catheter care policy, a privacy bag should be placed over the drainage bag when the resident is in public areas to preserve dignity. However, during an observation, the catheter bag was attached to the bed frame and was visible from the open doorway, displaying its contents. The blue snap-on catheter bag cover was present but left unsnapped, failing to conceal the bag or its contents. The resident involved had been admitted with diagnoses including hemiplegia, hemiparesis following cerebral infarction, and neuromuscular dysfunction of the bladder. The resident was documented as having severe cognitive impairment and was unable to participate in mental status interviews. The deficiency was confirmed during an interview with the DON, who acknowledged that the catheter cover had not been properly applied and did not provide adequate privacy for the resident.
Failure to Provide Disposable Premoistened Cleansing Cloths for Residents with Wounds
Penalty
Summary
The facility failed to provide reasonable accommodation of resident needs and preferences by discontinuing the use of disposable premoistened cleansing cloths for four residents who had wounds or fragile skin. Despite informing residents and staff that these cloths could be provided for incontinent residents with wounds due to their softer texture, the facility did not make them available. Observations confirmed the absence of these wipes in the supply room, and multiple residents and staff reported that the facility had stopped supplying them, replacing them with dry disposable wipes or washable cloths that were described as rough, thin, and inadequate for care. Residents with wounds and fragile skin expressed dissatisfaction with the alternative products, stating that the dry wipes were not soft, tore easily, and left lint, while the washable cloths were rough and irritating. Some residents and their families resorted to purchasing the premoistened wipes themselves to meet care needs. The Resident Council President and the facility Ombudsman both confirmed that the discontinuation of the wipes had been a topic of concern among residents, with reports of postponed or interrupted care due to inadequate supplies. Medical record reviews for the affected residents showed that they had significant medical conditions, including wounds requiring daily care, diabetes, end-stage renal disease, and impaired mobility. Orders for wound care and skin treatments were documented, and residents were assessed as dependent on staff for hygiene and toileting. Despite these needs and the facility's policy to accommodate resident preferences unless it endangered health or safety, the facility did not provide the premoistened cleansing cloths as previously indicated.
Failure to Maintain Safe Wheelchair Equipment and Provide Adequate Linens
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment for residents, specifically those dependent on wheelchairs and those requiring adequate linens for personal care. Two residents who relied on wheelchairs experienced issues with the condition and maintenance of their mobility devices. One resident's wheelchair had both armrests torn and missing all cushioning, causing discomfort, while another resident's personalized mechanical wheelchair had a broken armrest that had not been repaired for approximately two weeks after being damaged during a transfer. Staff, including nurses and therapists, were aware of these issues, but repairs were delayed or not initiated due to uncertainty about insurance coverage and lack of communication among staff and management. Additionally, the facility failed to provide adequate clean linens for resident care. On a specific day, staff reported a lack of clean towels and facecloths, resulting in postponed or interrupted personal hygiene care, such as bed baths and incontinence care. Staff described having to divide limited clean linens among residents and confirmed that some residents did not receive timely or sufficient care due to the shortage. The facility had discontinued the use of disposable premoistened cleansing cloths, relying instead on washable cloths and dry disposable wipes, which staff and residents described as inadequate for effective care, especially for those with fragile skin or wounds. Multiple staff interviews confirmed that the lack of clean linens and limited availability of mechanical lifts led to delays in resident care, including bathing, transfers, and incontinence care. Residents and their families reported dissatisfaction with the quality and timeliness of care, citing postponed assistance and the need to supply their own cleansing cloths. The facility's housekeeping supervisor attributed the linen shortage to miscommunication regarding staff scheduling, and there was confusion among staff about the location of clean linen storage, further contributing to the deficiency.
Failure to Timely Report Resident-on-Resident Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of resident-on-resident physical abuse to the State Agency within the required timeframe, as mandated by federal regulations. On the evening of 6/09/25, a certified nursing assistant (CNA) witnessed one resident strike another near the vending machines and immediately reported the incident to a registered nurse (RN) and a licensed practical nurse (LPN). The incident was also communicated to the Social Services Director (SSD) and the facility Administrator by the following day. Despite internal investigation and staff awareness, the allegation was not reported to the State Agency as required by facility policy and federal law. Interviews with staff confirmed that the incident was observed, reported, and discussed among multiple staff members, including the SSD, DON, and Administrator. The Administrator acknowledged awareness of the incident but chose not to report it to the State Agency, citing ongoing incidents between the two residents and a denial from the alleged victim during an interview. Documentation in the progress notes for the alleged perpetrator did not reflect the incident until nearly two weeks later, and the facility's investigation records confirmed that an internal review was conducted starting on the date of the incident. Both residents involved had a history of ongoing altercations and were known to seek each other out despite interventions such as room changes. The resident alleged to have committed the abuse had diagnoses of hemiplegia and diabetes, with no cognitive impairment per the most recent MDS. The alleged victim had chronic kidney disease, heart failure, and fluctuating cognitive status, with recent MDS scores indicating moderate to no cognitive impairment. The facility did not implement one-on-one supervision or other measures to ensure resident safety at the time of the incident.
Failure to Provide Adequate Nail Care During ADL
Penalty
Summary
The facility failed to provide adequate personal hygiene, specifically fingernail and toenail care, for two residents during Activities of Daily Living (ADL) care. Observations revealed that both residents had long fingernails, with a black substance under each nail, extending significantly past the ends of their fingers. One resident also had toenails that were excessively long. Both residents expressed a desire to have their nails trimmed. The facility's policy included nail care as part of ADL care, and supplies for nail care were available in the unit. Record reviews showed that one resident had severe cognitive impairment with diagnoses of Chronic Obstructive Pulmonary Disease and Alzheimer's Disease, while the other had no cognitive impairment and diagnoses including paraplegia and muscle weakness. Interviews with nursing staff and the DON confirmed that nail care was the responsibility of licensed nursing staff and was included in routine care, with a system in place for podiatrist visits for toenail care. Despite these policies and available resources, the necessary nail care was not provided to the two residents.
Failure to Assess and Document Resident After Fall
Penalty
Summary
The facility failed to evaluate and analyze hazards and risks, and did not assess a resident following a documented fall. According to the facility's fall policy, when a fall occurs, an incident and accident report should be completed, documentation should be initiated and continued for at least three days, a fall investigation and supervisor report should be completed, and the care plan should be updated. For one resident with a history of falls and diagnoses including Paranoid Schizophrenia, muscle weakness, and altered mental status, a fall was documented in the progress notes. However, there was no evidence of an incident report, follow-up monitoring, or required documentation related to this fall. Interviews with staff revealed confusion and lack of recall regarding the incident, with the LPN and staffing coordinator both unable to remember the fall or confirm that it was reported. The DON confirmed that protocol required assessment and documentation after a fall, but was unable to provide any documentation for the incident in question. The administrator also could not locate any incident report or related documentation, despite the fall being noted in the resident's progress notes. The resident was described as cognitively intact at the time of the incident.
Unsecured Medication Storage in Resident Room
Penalty
Summary
Facility staff failed to safely and securely store medications for one resident. During an observation, two vials of Ipratropium-Albuterol Inhalation Solution were found on the overbed table in the resident's room, with one vial opened and one unopened. The resident reported that nurses had left the medications for her and was unsure if there were more vials elsewhere. There was no individual medication storage cabinet in the room, and the Director of Nursing was unaware that medications were being stored unsecured in the resident's room. A review of facility policy indicated that medications and biologicals are to be stored safely, securely, and properly, accessible only to authorized personnel, and that bedside storage is only permitted with a prescriber's written order for residents able to self-administer. The resident had a BIMS score indicating no cognitive impairment and had an active physician order for the inhalation solution, but there was no physician order permitting storage of medications in the resident's room. Both the DON and Administrator confirmed that all medications were expected to be stored in locked medication rooms or carts.
Failure to Assess and Provide Adequate Staffing and Equipment
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine the resources necessary to competently care for residents during both routine operations and emergencies. The facility's assessment did not include information regarding the number of staff required or the number of mechanical lifts needed to meet the needs of the resident population. Policy review indicated that the facility was required to assess equipment, supplies, and personnel annually, but the actual assessment lacked these critical details. The staffing policy also referenced the facility assessment as a basis for determining sufficient staffing, but this was not reflected in practice. Interviews with the Staff Development Coordinator (SDC) revealed that staffing was scheduled based on per patient day (PPD) calculations without consideration of resident acuity or specific care needs on different units. The SDC was unaware of the facility assessment's role in staffing decisions. Observations and interviews with the DON and Administrator confirmed that only one full-body lift and one sit-to-stand lift were available, and that if a lift was in use on one unit, residents on the other unit experienced delays in care. The Administrator acknowledged that the facility assessment did not address the number of lifts or staffing levels needed to provide timely care, affecting all residents, including those with higher dependency and diagnoses such as morbid obesity.
Medication Security and Administration Deficiencies
Penalty
Summary
The facility failed to ensure the security of medications and biologicals, as evidenced by an unlocked and unattended medication cart and treatment cart, as well as medications left at a resident's bedside. During an observation on the North Unit, a medication cart was left unlocked and unattended for several minutes, with ten residents walking past it. The LPN responsible for the cart admitted it was an accident and acknowledged the potential risks of residents accessing the medications, which included liquid valproic acid and over-the-counter medications. Similarly, a treatment cart was left unlocked while a wound care nurse was attending to a resident, containing items such as scissors and antimicrobial solutions that should not be accessible to residents. Additionally, medications were left unattended at a resident's bedside. A resident was observed with a medication dispensing cup containing multiple tablets and capsules on their bedside table. The LPN confirmed that she left the medications unattended, which was against the facility's procedure, as it prevented her from knowing if the resident had taken the medication. The DON confirmed that leaving medications at the bedside was improper procedure. The resident involved was cognitively intact, with a BIMS score of 15, and had a medical history including a cerebral infarction.
Failure to Respect Resident Dignity and Privacy
Penalty
Summary
The facility failed to uphold residents' rights to dignity and respect in two separate incidents. In the first incident, a Certified Nurse Aide (CNA) attempted to check a resident for incontinence in the hallway against his wishes. The resident, who was listening to a church service, expressed his desire to delay care until later in the day. Despite this, the CNA proceeded to push the resident's wheelchair and attempted to look inside his pants, prompting the resident to resist and verbally express his desire to be left alone. The CNA acknowledged her actions were inappropriate, attributing them to her attempt to complete her duties before the end of her shift. The resident involved had a diagnosis of paraplegia and was cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 15. In the second incident, another resident was observed with a urinary catheter drainage bag visibly hanging from his wheelchair without a privacy cover, leaving the urine exposed. The resident, who was unsure of the duration or reason for having the catheter, noted that the bag is usually covered when he is outside his room. Both a Licensed Practical Nurse (LPN) and the Director of Nursing (DON) confirmed that catheter drainage bags should be kept in privacy bags to prevent the urine from being visible to others. This resident also had a BIMS score of 15, indicating cognitive intactness, and had a diagnosis of neuromuscular dysfunction of the bladder with an order for a suprapubic catheter.
Removal Plan
- CNA will no longer be assigned to the resident
- District Ombudsman was contacted
Failure to Label and Date Enteral Feeding Bags
Penalty
Summary
The facility failed to properly label and date enteral feeding bags for a resident receiving nutrition via a feeding tube. During multiple observations, it was noted that the feeding tube bags for Resident #24 were not labeled with the name of the formula, the date, or the time when the bags were hung. This was observed on three separate occasions, indicating a consistent failure to adhere to the facility's policy regarding enteral feeding procedures. Interviews with staff revealed a lack of accountability and communication between shifts. An LPN confirmed that the feeding bags were not labeled and explained that it was the responsibility of the previous shift to change and label the bags. The Director of Nursing also stated that it was the night nurses' responsibility to ensure the bags were labeled correctly. Despite these established responsibilities, the feeding bags remained unlabeled, demonstrating a breakdown in the facility's protocol for managing enteral feedings.
Failure to Revise Care Plan Following Change in Physician's Order
Penalty
Summary
The facility failed to revise a comprehensive care plan intervention when a physician's order changed for a resident diagnosed with Type 2 Diabetes Mellitus. The resident had a previous physician's order for HumaLog KwikPen with sliding scale coverage, which was discontinued. A new order was issued for weekly accuchecks, but the care plan was not updated to reflect this change. This oversight was identified through staff interviews, record reviews, and facility policy reviews. The care plan nurse, responsible for updating care plans based on new orders, was on vacation at the time of the deficiency. The LPN and the Director of Nursing confirmed that the care plan had not been revised, which could lead to confusion in resident care. The facility's policy requires care plans to be revised as residents' conditions and orders change, but this was not adhered to in this instance.
Failure to Conduct Smoking Safety Assessment
Penalty
Summary
The facility failed to conduct a safety smoking assessment for a resident, which is a violation of their policy to provide a safe environment for residents who smoke. The policy requires that residents with a known history of smoking be evaluated on admission, quarterly, and as needed for safety awareness and any physical limitations related to smoking safety. However, Resident #1, who has been a resident since 2013 and has a history of smoking, did not have a current smoking safety evaluation completed since 2021. This oversight was confirmed during interviews with the resident, an LPN, and the Director of Nurses (DON). Resident #1, who is cognitively intact with a Brief Interview for Mental Status score of 15, has been using tobacco as indicated in her Comprehensive Annual Minimum Data Set (MDS) assessment. Despite her long-term residency and continued smoking habit, the facility failed to reassess her smoking safety, which could potentially put her at risk for burns. The LPN and DON acknowledged the lapse in conducting the necessary assessments, attributing it to an oversight in the nursing supervisors' responsibilities to complete the assessment form as per the facility's policy.
Failure to Secure Indwelling Catheter Tubing
Penalty
Summary
The facility failed to ensure proper care for a resident with an indwelling catheter, as observed during a survey. The resident, who was admitted with a diagnosis of neuromuscular dysfunction of the bladder, had a physician's order to check the urinary catheter leg strap every shift and replace it as needed. However, during an observation of catheter care, it was noted that the resident did not have a leg strap in place to secure the catheter tubing. Both the CNA and LPN confirmed the absence of the leg strap, which is essential to prevent the catheter tubing from pulling or becoming dislodged. The facility's policy on catheter care, dated 8/25/14, clearly states the importance of securing the catheter to prevent catheter-associated urinary tract infections. Despite this policy, the staff failed to adhere to the procedure, as evidenced by the lack of a leg strap for the resident's catheter. The Director of Nursing confirmed that all residents with an indwelling catheter should have a leg strap, and the Administrator expressed an expectation for staff to provide quality care. This deficiency highlights a lapse in following established protocols for catheter care within the facility.
Failure to Ensure Respectful and Dignified Treatment of Residents
Penalty
Summary
The facility failed to ensure that residents were treated and spoken to in a dignified and respectful manner. This deficiency was observed in the cases of two residents. The facility's policy on employee behavior mandates courteous treatment of all residents, visitors, and coworkers, and prohibits offensive behavior. However, multiple interviews and record reviews revealed that an LPN routinely spoke to residents in a loud, rude, and aggressive manner. The facility Ombudsman confirmed receiving complaints about the LPN's behavior, and several residents and a family member provided specific examples of the LPN yelling at residents and giving orders in a disrespectful tone. One resident reported that the LPN was rude and disrespectful, often yelling at residents to go to bed or return to their rooms. Another resident and her family member corroborated these observations, noting that the LPN's loud and aggressive behavior was more than just an attempt to be heard. The family member added that some residents seemed unable to understand the LPN's commands. The previous Resident Council President also mentioned that the LPN's behavior had been discussed in council meetings, although it was unclear if these concerns were formally recorded. The Social Services Director confirmed receiving a grievance about the LPN's behavior, and the Assistant Director of Nursing noted that the LPN had already received multiple coaching and verbal warnings regarding therapeutic communication. Despite routine in-service training on resident rights and respectful treatment, the LPN's behavior persisted. Record reviews showed that the LPN had received a verbal warning and additional training on conduct and therapeutic communication just a month prior to the reported incidents. The residents involved had varying degrees of cognitive function, with one being cognitively intact and the other showing no cognitive impairment.
Resident Elopement Due to Inadequate Supervision and Unsecured Door
Penalty
Summary
The facility failed to provide adequate supervision to prevent a vulnerable resident from exiting the facility unnoticed and unsupervised. The resident was last observed in his room at 1:15 AM, but staff were unaware of his absence until 3:15 AM. After a search of the building and perimeter, it was determined that the resident had left the facility. The resident was found by the police approximately 12 miles away, having been off the facility grounds and unsupervised for about six to eight hours. The resident, who was cognitively intact and not identified as a wanderer or elopement risk, managed to kick open an entrance door to exit the facility. The facility's failure to ensure the entrance door was secure and to provide adequate supervision put the resident and other vulnerable residents at risk for serious harm. The incident was determined to be an Immediate Jeopardy and Substandard Quality of Care. Interviews and record reviews revealed that the facility staff were unaware of the resident's absence until a staff member entered his room at 3:15 AM. The resident was eventually located by the police, wearing appropriate clothing and carrying some belongings. The facility's policies and procedures for missing residents were initiated, but the initial failure to secure the entrance door and provide adequate supervision led to the resident's elopement.
Removal Plan
- The Certified Nursing Assistant (CNA) observed the residents' room and noted he was not present. She immediately notified the Licensed Practical Nurse (LPN) on duty. All staff on the unit began a search for the resident throughout the north unit and then moved to the south unit; at this time, all staff were directed by the LPN to conduct a search of all areas of the building and the perimeter.
- The LPN notified the Administrator in Training (AIT) that the staff searched the building and perimeter and could not locate the resident. The AIT notified the Administrator and Director of Nursing (DON) immediately after speaking with the nurse. The Administrator gave instructions to contact the Maintenance Supervisor and the Police Department. The LPN attempted to contact the resident's next of kin and the number was disconnected.
- The Maintenance Supervisor arrived at the facility. He checked all exit doors for proper functioning and noted all doors were secure. He began a search of the perimeter including outside buildings and checked all windows noting all windows were secure.
- A complete headcount was conducted by the nursing staff and all other residents were located.
- A search team was assembled by the DON and Maintenance Supervisor to search surrounding buildings, including churches, convenience stores, local bus stations and all open businesses. The LPN began making calls to all surrounding police stations. The Administrator contacted all local hospitals.
- The Officer assigned to the case arrived at the facility and completed a missing person's report.
- The Administrator notified the resident's physician to update the missing resident's status.
- The Police Department confirmed with the Administrator that the resident was safe and secure at the Police Station.
- The Director of Nursing and Social Service Director went to the Police Station, assessed the resident, found no issues or psychosocial harm then transferred the resident to the emergency room because he refused transport by ambulance. The resident was calm and expressed confidence in his purpose for leaving the facility. He stated he kicked the door, left the facility, walked to the corner of the road, caught a ride with two white ladies that helped him make a sign so he could get to (name of city) to see his family.
- The DON arrived at the hospital, gave history of incident and medical information to the Physician along with current medications and morning medications that he had not received at this time. The DON remained with the resident while the nurse obtained vital signs including a blood glucose level and body audit. No issues were noted with skin assessments, all vital signs were within normal limits and the resident stated he felt fine, but his legs were sore. The Physician ordered labs and stated they would complete medical clearance for admittance.
- A Quality Assurance Performance Improvement (QAPI) committee meeting was held regarding the incident involving Resident # 1. In attendance were the Administrator, the DON, the AIT, the Care Plan Nurse, the Assistant Director of Nursing (ADON)/Infection Preventionist (IP), the Business Office Manager, the Maintenance Supervisor, the Wound Care Nurse, Medical Director, the Regional Nurse Consultant, the Regional Director of Operations, and the Social Services Director (SSD).
- The QAPI committee reviewed the incident, actions taken, and the policy was reviewed with no recommendations for change.
- All facility staff were 100% in-serviced regarding elopement/missing resident policies and procedures prior to returning to work by the AIT and the DON.
- One hundred percent (100%) of all residents were assessed for elopement risk by the Wound Care Nurse and DON.
- Care Plan Nurse performed a 100% audit of all resident's care plans for those identified as an elopement risk.
- DON completed a 100% audit of all residents that were identified as an elopement risk to include visual monitoring, wander guard bracelets and testing.
- 100% audit of the elopement book was performed by the Social Services Director and to ensure that all pictures were current.
- Maintenance Supervisor performed elopement drills on all shifts, this will continue for four (4) weeks and monthly thereafter and brought before the QAPI committee each month for review and recommendations. Any issues will be addressed immediately by the Administrator and DON.
- Maintenance Supervisor changed all door codes in the facility.
- AIT ordered keypad covers for all door keypads in the building.
- Maintenance Supervisor placed door alarms on all doors in the facility. The alarms will be monitored daily, and any issues will be addressed immediately by the Administrator and brought before the QAPI committee monthly for review and recommendations.
- Maintenance Supervisor contacted the alarm company to schedule testing of all doors in the building.
- State Department of Health (SA) was notified of the incident.
- The Attorney General's office (AGO) was notified of the incident.
Failure to Answer Call Lights Timely
Penalty
Summary
The facility failed to treat residents with dignity and respect by not consistently ensuring that call lights were answered in a timely manner. This deficiency was observed in three sampled residents and one unsampled resident. Resident #32 reported that it took staff over two hours to respond to call lights, leaving him wet and sometimes soiled. Resident #1 stated that she had to lay in urine and bowel movement for over an hour and had complained to the Ombudsman. Resident #45 also complained about the staff not answering call lights timely. Additionally, a grievance was filed by the wife of an unsampled resident regarding the same issue. The Ombudsman confirmed receiving recent complaints about the untimely response to call lights and had discussed the issue with the facility's Assistant Administrator, Social Service Director, and Activity Director. The Director of Nurses acknowledged being aware of the complaints and stated that staff had been in-serviced on the importance of answering call lights promptly. The Activity Director and Social Service Director also confirmed receiving complaints and stated that the Director of Nursing had conducted in-services with the staff. The Administrator confirmed that residents had complained during resident council meetings and that multiple in-services had been conducted to address the issue, with the last one occurring in December 2023.
Failure to Obtain Informed Consent for Bed Rails
Penalty
Summary
The facility failed to obtain informed consent for the use of bed rails for seven out of eighteen residents reviewed. The facility's policy requires that residents or their representatives be informed about the benefits and potential hazards associated with bed rails and that informed consent be obtained before their use. However, observations and medical record reviews revealed that residents #1, #14, #24, #31, #45, #81, and #142 had bed rails in use without signed informed consent forms in their medical records. This was confirmed through multiple observations and interviews with facility staff, including the Maintenance Director, Administrator, and Director of Nursing (DON), who acknowledged the absence of signed consent forms for bed rails in the residents' charts. During the survey, it was observed that the facility had bed rails installed and in use for the mentioned residents without following the required protocol of obtaining informed consent. The Administrator and DON confirmed that the facility did not have a bed rail consent process in place at the time of the survey. This lack of compliance with the facility's policy and regulatory requirements led to the deficiency being cited by the surveyors.
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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