Poplar Springs Nursing Ctr, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Meridian, Mississippi.
- Location
- 6615 Poplar Springs Dr, Meridian, Mississippi 39305
- CMS Provider Number
- 255315
- Inspections on file
- 20
- Latest survey
- July 24, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Poplar Springs Nursing Ctr, Llc during CMS and state inspections, most recent first.
A resident's privacy was compromised when personal care instructions were posted on the outside of their door and next to their bed, detailing their care schedule. Multiple staff, including an LPN, Social Services Director, DON, and Administrator, acknowledged this as a violation of privacy. The resident had spastic quadriplegic cerebral palsy and intact cognition. Facility policy requires privacy and confidentiality, which was not maintained in this instance.
A resident with a history of Parkinson's Disease and Schizophrenia, who was confirmed by staff to be blind and observed bumping into objects, was inaccurately documented as having adequate vision on the MDS assessment. Despite staff awareness and supporting documentation of the resident's blindness, the MDS and care plan did not reflect the true vision status.
A resident with blindness was not provided with a comprehensive care plan addressing their visual impairment, despite staff awareness and facility policy requirements. Observations showed the resident bumping into objects and needing assistance, but the care plan and MDS did not reflect the resident's blindness.
A resident with Parkinson's Disease and Schizophrenia, who was blind, was not properly identified, assessed, or provided with care planning for his visual impairment. Staff and the DON were aware of his blindness and observed him bumping into walls and requiring assistance, but facility records did not reflect any formal assessment or interventions for his vision, contrary to facility policy.
A significant medication error occurred when a nurse incorrectly transcribed and administered Lasix at twice the prescribed daily dose for a resident with severe cognitive impairment and heart disease. The error resulted from a miscommunication of the order, which was sent via encrypted text and entered into the system without proper verification.
The facility failed to properly store food and maintain food quality, as observed by the presence of spoiled tomatoes with white biological growth in a refrigerator and open bottles of dry seasonings on the spice rack. Both the Kitchen Supervisor and Administrator acknowledged these lapses in food safety standards.
Staff failed to follow infection control policies by transporting clean linens uncovered, placing a dirty cup on the linen cart, and allowing clean linens to come into contact with worn clothing. These actions were observed during routine operations and confirmed by interviews with facility leadership, despite the staff member having received infection control training.
A resident with a history of atrial fibrillation and anxiety disorder, who was cognitively intact, was left waiting for assistance after requesting help to transfer to her recliner. A CNA turned off the call light without providing immediate help and later returned using an inappropriate tone, stating that staff were short and she had not had her break. The resident was found crying and reported feeling dismissed and disrespected by the CNA's actions and words. Staff interviews and surveillance confirmed the delay and the inappropriate interaction.
A resident with a history of Atrial Fibrillation and Anxiety Disorder, who was cognitively intact, alleged verbal abuse and neglect by a CNA. The facility's investigation did not include interviews with other cognitively intact residents assigned to the CNA, as required by policy, and surveillance video was not reviewed until after state agency involvement.
A facility failed to adhere to its policy of dating oxygen tubing for a resident with COPD, leading to a deficiency. The resident had a physician's order for oxygen therapy, but observations revealed the tubing was not dated as required. Interviews with an LPN and the DON confirmed the oversight, despite the policy being reviewed during staff orientation.
A facility failed to ensure proper hand hygiene during perineal care for a resident with severe cognitive impairment and hemiplegia. CNAs washed hands without soap due to an empty dispenser and did not sanitize between glove changes. An LPN entered and exited the room without changing gloves. Interviews confirmed the failure to follow infection control protocols, posing a risk of contamination and infection.
The facility failed to maintain a safe and homelike environment due to broken and missing floor tiles in the hallway leading to the therapy room. Staff interviews confirmed awareness of the hazard, although no resident falls were reported. The Administrator and Maintenance Director acknowledged the potential tripping hazard posed by the condition of the floor.
A resident with a mood disorder and dementia exhibited sexually inappropriate behavior, verbal aggression, and refusal of care, but the facility failed to develop a comprehensive care plan with specific interventions. Despite ongoing issues documented in psychiatric notes, the care plan only included medication administration and monitoring for behavior changes. Interviews with staff confirmed the lack of special interventions to manage the resident's behaviors.
A resident with a catheter and a history of a sacral pressure ulcer did not receive adequate perineal care from CNAs, leading to potential risks of infection and skin breakdown. The CNAs failed to thoroughly clean the resident, leaving feces in critical areas, which was only discovered after prompting by a State Agency. The resident was dependent on staff for toileting care, and the CNA admitted to not ensuring complete cleanliness.
A resident with multiple cardiac conditions received crushed extended-release and delayed-release medications, contrary to physician orders and facility policy, resulting in a medication error rate of 10.26%. An LPN crushed the medications due to perceived swallowing difficulties, but the DON confirmed that such medications should not be crushed without specific physician instructions.
A resident was sent on therapeutic leave without all prescribed medications, including insulin and other essential drugs, despite the leave being planned in advance. The DON and an LPN confirmed the oversight, acknowledging that the facility failed to follow procedures to ensure all active medications were provided, potentially impacting the resident's health.
A resident's Norco medication was misappropriated by an LPN, who signed out the medication 19 times without a prescription. The resident, who had Parkinson's Disease and was cognitively intact, tested negative for opioids, raising suspicion. An investigation revealed the LPN tested positive for opioids and morphine, leading to her termination and reporting to relevant authorities.
Resident Privacy Breach Due to Public Posting of Care Instructions
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of a resident's personal and medical information by posting personal care instructions on the exterior of the resident's door and on the wall next to her bed. The posted sign included specific instructions regarding the resident's care schedule, such as getting the resident up three times per week on specified days prior to her bath, as requested by the resident and family. This action was observed during a facility survey, and the sign was acknowledged by multiple staff members, including an LPN, the Social Services Director, the DON, and the Administrator, as a violation of the resident's privacy. The resident involved had been admitted with diagnoses including Spastic Quadriplegic Cerebral Palsy and had intact cognition, as indicated by a BIMS score of 15. The facility's own policy on resident rights, dated 4/2012, requires employees to treat all residents with kindness, respect, and dignity, and specifically guarantees privacy and confidentiality. The posting of the care instructions in a public area accessible to anyone entering the room constituted a failure to uphold these rights.
Inaccurate MDS Assessment of Resident's Vision Status
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's vision status. Multiple staff members, including the Director of Nursing, an LPN, and the MDS Coordinator, confirmed that the resident was blind. Observations showed the resident required assistance to exit the room, bumped into walls, and relied on verbal directions from a roommate. Despite these clear indications of visual impairment, the most recent MDS assessment documented the resident's vision as adequate. A review of the resident's records revealed a history of Parkinson's Disease and Schizophrenia, and a fall assessment from earlier in the year indicated an inadequate vision pattern. The resident was cognitively intact, as evidenced by a BIMS score of 15. Staff interviews and documentation confirmed awareness of the resident's blindness, yet this was not accurately reflected in the MDS or care plan as required by facility policy and CMS protocol.
Failure to Address Blindness in Resident Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed the visual impairment of a resident who was blind. Despite the facility's policy requiring individualized, person-centered care plans based on thorough assessments, the resident's care plan did not include any focus area or interventions related to blindness or visual impairment. Observations showed the resident bumping into walls and requiring assistance from a roommate to exit the room. Interviews with staff, including the DON, LPN, and RN/MDS Coordinators, confirmed the resident was blind and that this status should have been reflected in the care plan. However, the care plan lacked any mention of the resident's vision status, and the most recent MDS inaccurately documented the resident's vision as adequate. The resident had been admitted to the facility with diagnoses including Parkinson's Disease and Schizophrenia and was cognitively intact according to the latest assessment. Staff interviews revealed that some were aware of the resident's blindness and had witnessed incidents where the resident bumped into objects, while others were unaware of the resident's visual impairment. The lack of documentation and care planning for the resident's blindness resulted in the deficiency cited by surveyors.
Failure to Identify and Address Resident's Visual Impairment
Penalty
Summary
The facility failed to identify, assess, or address the visual impairment of a resident, despite multiple observations and staff confirmations that the resident was blind. The resident was seen bumping into walls and objects while attempting to navigate the facility, and required verbal directions and physical guidance from staff and his roommate to move safely. Interviews with the DON, CNAs, and an LPN confirmed awareness of the resident's blindness and his frequent collisions with objects. However, the facility's records did not reflect any formal identification, assessment, or care planning for his visual impairment. A review of the resident's medical record showed a history of Parkinson's Disease and Schizophrenia, and a recent MDS assessment inaccurately documented his vision as adequate, despite a fall assessment indicating inadequate vision and nursing notes describing his difficulty seeing and running into walls. The facility's policy required comprehensive assessment and ongoing monitoring of vision, but there was no documentation that these steps were taken for this resident. The deficiency was identified through observation, interviews, and record review.
Significant Medication Error Due to Incorrect Transcription of Lasix Order
Penalty
Summary
A significant medication error occurred when a nurse incorrectly transcribed and administered Lasix at a higher dose than prescribed for a resident with a history of atherosclerotic heart disease and severe cognitive impairment. The nurse practitioner had ordered an increase in Lasix to 40 mg by mouth daily, communicated via encrypted text to the charge nurse. However, the registered nurse entered the order as Lasix 40 mg twice a day instead of the intended once daily dose. This discrepancy resulted in the resident receiving double the prescribed amount of Lasix. The error was identified when the nurse practitioner reviewed the resident's medication regimen and discovered the incorrect dosing. The Director of Nursing confirmed that the facility's process involved the nurse practitioner sending orders via encrypted text to the charge nurse, who then entered them into the system without additional oversight. The administrator acknowledged the transcription error and recognized the need for improved verification and communication of medication orders.
Failure to Maintain Food Safety Standards in Kitchen Storage and Handling
Penalty
Summary
During an observation and staff interview, the facility failed to store food and maintain food quality in accordance with professional standards for food safety. Specifically, refrigerator #1 in the kitchen contained 11 tomatoes with visible white biological growth, indicating spoilage. Additionally, three bottles of dry seasonings were found on the spice rack with their lids open, leaving the contents exposed. The Kitchen Supervisor acknowledged both the presence of overly ripe produce and the opened spice bottles, stating responsibility for maintaining safety and quality standards in the kitchen. The Administrator also acknowledged these issues and confirmed that the Kitchen Supervisor is expected to perform regular checks on food quality and standards. No information about residents or their medical conditions was provided in relation to this deficiency.
Failure to Properly Handle and Transport Clean Linens
Penalty
Summary
The facility failed to prevent the potential spread of infection by not adhering to established infection prevention and control policies regarding the handling and transport of clean linens. During observations, a laundry worker was seen transporting a cart of clean linens with the plastic covering flipped over, leaving the linens exposed, and an empty disposable beverage cup was placed on top of the cart near the linens. The same worker was also observed transferring a clean blanket by resting it against his upper body before refolding and placing it on the clean linen cart. The laundry worker stated he was unaware that linens should be covered during transport and that clean linens should not be placed against worn clothing. Interviews with facility staff, including the District Manager of Housekeeping, the Infection Preventionist nurse, and the DON, confirmed that these actions were not in compliance with facility policy, which requires clean linens to be covered during transport and not to be placed against staff clothing. Review of facility policies and onboarding documents indicated that the laundry worker had received training on infection control, but failed to follow the procedures as outlined.
Resident Left Waiting and Spoken to Disrespectfully by CNA
Penalty
Summary
A resident with a history of atrial fibrillation and anxiety disorder, who was cognitively intact, requested assistance transferring to her recliner by pressing her call light. A CNA entered the room, turned off the call light, acknowledged the request, but did not provide assistance at that time. The resident waited approximately two hours before receiving help, during which she pressed her call light again. When the CNA returned, she used an inappropriate tone and language, telling the resident that staff were short and she had not had her break, which left the resident feeling dismissed and disrespected. The incident was witnessed in part by another CNA, who confirmed that the first CNA complained about being short staffed in front of the resident and left the room to attend to other duties. Multiple staff interviews and a review of surveillance footage confirmed the timeline of the call light being activated, turned off, and the eventual use of the lift to assist the resident. The resident was found crying in her room by the Activities Director, who reported the situation to administration. Interviews with various staff, including the Administrator, DON, and RN/Unit Manager, confirmed that staffing was sufficient on the day of the incident and that the CNA had completed required training on abuse, neglect, and the Vulnerable Adult Act. The resident reported feeling very upset and cried as a result of the CNA's actions and words. Subsequent assessments by the Social Worker and Nurse Practitioner found no signs of psychological harm, but the resident expressed relief upon learning that the CNA was no longer employed at the facility.
Failure to Interview Other Cognitively Intact Residents During Abuse Investigation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a cognitively intact resident who reported verbal abuse and neglect by a CNA. The resident, who had a history of Atrial Fibrillation and Anxiety Disorder and was assessed as cognitively intact with a BIMS score of 15, alleged that after returning to her room and activating her call light for assistance, the CNA turned off the call light without providing help and later made dismissive remarks about being short-staffed and needing a break. The incident was discovered when the Activities Director found the resident crying in her room. Despite the facility's abuse policy requiring resident statements as part of the investigation, the written investigation did not include interviews with other residents who received care from the same CNA, particularly those with a BIMS score of 13 or higher who could have provided relevant information. The Administrator, DON, and Social Services Director all confirmed that they did not interview other cognitively intact residents assigned to the CNA during the shift, and the Administrator also acknowledged that surveillance video was not reviewed until after the state agency's entrance.
Failure to Date Oxygen Tubing for Resident with COPD
Penalty
Summary
The facility failed to provide respiratory care in accordance with its policy, which led to a deficiency in the care of a resident with Chronic Obstructive Pulmonary Disease (COPD). The resident, who was admitted to the facility with a diagnosis of COPD, had a physician's order for oxygen therapy at 2 liters per minute via nasal cannula as needed. During observations on two consecutive days, it was noted that the oxygen tubing used by the resident was not dated, which is a requirement according to the facility's policy. This policy mandates that all respiratory tubing be replaced weekly and dated to ensure proper tracking and reduce the risk of infectious diseases and bacterial exposure. Interviews with facility staff, including a Licensed Practical Nurse (LPN) responsible for the resident's care and the Director of Nursing (DON), confirmed the oversight. The LPN admitted to being unaware of the requirement to date the oxygen tubing, while the DON acknowledged that the policy was reviewed with all staff during orientation. The DON also confirmed that the oxygen tubing is typically changed on Sunday nights by the night shift. Despite these procedures being in place, the failure to date the tubing as per policy was identified as a deficiency in the facility's respiratory care practices.
Inadequate Hand Hygiene During Perineal Care
Penalty
Summary
The facility failed to ensure proper hand hygiene during perineal care for a resident, leading to a deficiency in infection prevention and control. During an observation, two CNAs were seen preparing to provide perineal care for a resident with hemiplegia and severe cognitive impairment. The CNAs found the soap dispenser empty and proceeded to wash their hands without soap. One CNA left the room to get an LPN to pause a feeding pump but did not perform hand hygiene after removing gloves or before applying new ones. The LPN entered the room wearing gloves, paused the feeding pump, and exited without changing gloves. During the care, one CNA removed and reapplied her glove multiple times without performing hand hygiene between changes. Interviews with the CNAs, LPN, Infection Preventionist, ADON, and DON confirmed the failure to follow proper infection control protocols. The CNAs admitted to not using soap during handwashing and not sanitizing hands between glove changes, acknowledging the risk of bacteria remaining on their hands. The LPN admitted to not washing hands or removing gloves before exiting the room, which could spread infection. The Infection Preventionist and ADON confirmed the improper hand hygiene and glove handling, emphasizing the risk of contamination and infection. The DON acknowledged the failure to follow protocols, which could lead to cross-contamination and pose risks to the resident.
Facility Fails to Maintain Safe Environment Due to Broken Floor Tiles
Penalty
Summary
The facility failed to ensure a safe and homelike environment for its residents, as evidenced by broken and missing floor tiles in the hallway leading to the therapy room. During an observation, it was noted that several floor tiles were broken, and there was a section where tiles were missing, creating an indentation approximately six inches wide. This condition was identified in one of the eight hallways observed, specifically in the therapy room hallway. Interviews with facility staff, including the Rehabilitation Technician, Administrator, and Maintenance Director, confirmed awareness of the issue. The Rehabilitation Technician acknowledged the hazard posed by the broken and missing tiles, although no resident falls had been reported. The Administrator and Maintenance Director both recognized the potential tripping hazard due to the crack in the cement and tiles, which could affect both residents and staff accessing the therapy gym.
Failure to Develop Comprehensive Care Plan for Resident with Behavioral Issues
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident with behaviors related to a mood disorder. The care plan lacked specific interventions to manage the resident's sexually inappropriate behaviors, verbal aggression, and refusal of care and medications. Despite the resident's history of such behaviors, the care plan only included administering medications as ordered and monitoring for signs and symptoms of behavior changes, without addressing the specific behavioral issues. The resident, who was admitted with diagnoses of Persistent Mood Disorder and Dementia with Behavioral Disturbance, exhibited symptoms such as agitation, verbal aggression, and sexually inappropriate behavior. These behaviors were documented in multiple psychiatric progress notes, indicating the resident's need for frequent redirection and difficulty in redirecting. The resident also refused care and medications, and these behaviors significantly interfered with the resident's care. Interviews with facility staff, including an LPN, the DON, and a Psychiatric NP, confirmed the resident's ongoing behavioral issues. The staff reported that the resident continued to exhibit sexually inappropriate behavior and verbal aggression, and there were no special interventions developed to address these behaviors. The Psychiatric NP noted that medication management was ineffective, and behavioral monitoring and documentation were deferred to nursing services.
Inadequate Perineal Care for Resident with Catheter
Penalty
Summary
The facility failed to provide adequate perineal care for a resident, leading to potential complications. During an observation, two CNAs were responsible for cleaning a resident with a catheter. They used pre-moistened disposable wipes to clean the resident's penis, catheter tubing, and buttocks. However, after claiming the perineal care was complete, it was discovered that the resident was not thoroughly cleaned. Upon further inspection prompted by the State Agency, feces were found below the resident's anus and underneath the scrotum, requiring additional cleaning. The resident involved had been admitted to the facility with a diagnosis of a pressure ulcer in the sacral region and was dependent on staff for toileting care, as indicated by a BIMS score of nine, showing moderate impairment. The CNA involved admitted to not thoroughly checking the resident's cleanliness, which could lead to skin breakdown and infection. The Director of Nursing confirmed that the CNA should have ensured the resident was completely clean to prevent such risks.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by four errors observed out of 39 medication administration opportunities, resulting in a medication error rate of 10.26%. This deficiency affected one of the three residents observed during the medication pass. The facility's policy on medication administration, dated September 1, 2022, specifies that medications should be administered in accordance with professional standards, including not crushing medications that have 'do not crush' instructions, such as slow-release and enteric-coated medications. Resident #27, who was admitted on January 25, 2023, with diagnoses including Unspecified Atrial Fibrillation, Acute Systolic Congestive Heart Failure, Bradycardia, and Hypertensive Heart Disease with Heart Failure, was affected by this deficiency. The resident had active physician's orders for several extended-release and delayed-release medications, none of which included instructions to crush them. However, during an observation, an LPN crushed and administered these medications to the resident, believing the resident had difficulty swallowing. The DON confirmed that extended-release and delayed-release medications should not be crushed unless specified by a physician, as crushing them can alter their intended delivery and effectiveness.
Failure to Provide Medications for Resident on Therapeutic Leave
Penalty
Summary
The facility failed to provide services in an acceptable standard of practice when a resident was sent on therapeutic leave without all physician-prescribed medications. The resident's daughter reported that her mother was sent home without essential medications, including Aspirin, Basaglar Kwik Pen (insulin), Fiasp Injection insulin, Miralax Powder, Protonix, Silvadene Cream, and Zyrtec Allergy. This therapeutic leave was planned in advance, and the facility was aware of the resident's need for these medications during her out-of-state trip. Interviews with the Director of Nursing (DON) and a Licensed Practical Nurse (LPN) confirmed the oversight. The DON stated that the procedure for residents on therapeutic leave is to verify and send all active medications with the resident. The LPN, responsible for preparing the medications, admitted to the oversight, acknowledging that the resident's family received incomplete medication supplies. The record review showed active physician orders for the missing medications, highlighting the facility's failure to adhere to its procedures, potentially impacting the resident's health.
Misappropriation of Resident's Medication by LPN
Penalty
Summary
The facility failed to protect a resident from the misappropriation of a controlled medication, specifically Norco, by a Licensed Practical Nurse (LPN). The incident involved a resident who was prescribed Norco 10-325 milligrams to be taken as needed for pain. However, a urine drug screen requested by the Nurse Practitioner (NP) revealed that the resident tested negative for opioids, despite the medication being signed out 21 times over a period of 11 days. This discrepancy raised suspicion and led to an investigation by the Director of Nurses (DON). The investigation uncovered that LPN #1 had signed out the medication 19 times and tested positive for opioids and morphine, without having a valid prescription. LPN #1 admitted to taking pain medication at home without a current prescription. The resident, who was cognitively intact and had a history of Parkinson's Disease, confirmed receiving only a few pain pills and stated that he did not usually require pain medication. The NP and DON confirmed that the resident required very little pain medication, which further supported the suspicion of misappropriation. The facility's policy on abuse, including misappropriation of resident property, was reviewed, and it was determined that the facility failed to protect the resident's medication from being wrongfully used by LPN #1. The incident was reported to the State Agency, Attorney General Office, State Board of Nursing, and Board of Pharmacy. The facility conducted a thorough investigation, including testing all nurses who administered the medication and reviewing the narcotic administration log.
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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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