Sardis Community Nh
Inspection history, citations, penalties and survey trends for this long-term care facility in Sardis, Mississippi.
- Location
- 613 East Lee Street, Sardis, Mississippi 38666
- CMS Provider Number
- 255279
- Inspections on file
- 20
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Sardis Community Nh during CMS and state inspections, most recent first.
A resident with a history of diabetes mellitus and cerebral infarction developed a new excoriated area on the sacrum that required treatment and monitoring, as documented in progress notes. Facility policy requires comprehensive care plans with measurable objectives, time frames, and service descriptions, reviewed and revised on an ongoing basis. However, record review showed no care plan was developed to address the new sacral skin breakdown. In interviews, an RN stated that care plans are used to guide staff in how to care for residents, and the MDS nurse confirmed that no care plan had been created for this newly identified skin issue, despite acknowledging that one should have been implemented.
A resident with a history of diabetes mellitus and cerebral infarction developed an excoriated, reddened sacral area, for which an RN obtained an order to cleanse with wound cleanser, pat dry, and apply zinc oxide every shift until healed. Although the facility’s skin policy required appropriate wound treatment, review of the MAR/TAR showed no documentation that the ordered treatment was provided. During interviews, the RN confirmed the absence of treatment documentation, and the DON explained that the treatment order did not appear on the MAR/TAR because an incorrect order type was selected when entering it, resulting in the treatment being missed.
A resident with moderate cognitive impairment and hemiplegia was subjected to abuse when a nurse aide pulled the resident from a seated position onto the floor, verbally berated the resident, and sprayed an aerosol substance on the resident's lower body. Multiple staff and the resident confirmed the aide's actions, which resulted in the resident experiencing fear, distress, and compromised dignity.
A resident with moderate cognitive impairment was found on the floor after an altercation with a nurse aide, who was reported by witnesses to have pulled a pillow from under the resident and sprayed them with an aerosol substance. Multiple staff provided written witness statements, but these were not included in the facility's abuse investigation documentation. The administrator dismissed the allegation due to conflicting accounts and lack of proof of intent, despite evidence from several witnesses.
Two residents did not receive appropriate care planning: one resident on anticoagulant therapy lacked a care plan for monitoring bleeding risks, and another resident with Parkinson's Disease did not receive the required assistance with bathing and showering as outlined in their ADL care plan. Both deficiencies were confirmed by staff interviews and record reviews.
A resident with Parkinson's Disease, who was cognitively intact, did not receive scheduled bathing assistance as required. Despite being on a set bathing schedule, the resident was observed with a foul odor and unchanged clothing over multiple days, and both the resident and his roommate reported no baths or showers since admission. Staff could not recall or document any bathing provided, and the DON confirmed the resident should have received this care.
A resident's room had a large area of missing paint that had not been repaired since admission, despite the resident's concerns and awareness by facility staff. The resident, who has moderate cognitive impairment, reported feeling uncomfortable with the room's condition, especially during family visits. Facility policy requires a homelike environment, but this standard was not met.
A resident with severe cognitive impairment and a history of cerebral hemorrhage was incorrectly coded on the admission MDS as having bed rails used as a restraint, despite documentation and staff interviews confirming the rails were for positioning and bed mobility. Facility staff acknowledged the coding error after review and observation.
A resident prescribed Apixaban for acute embolism and thrombosis did not have a monitoring protocol in place to observe for adverse effects such as bleeding, despite facility policy requiring such observation. Staff interviews, including those with an LPN, the MDS Coordinator, and the DON, confirmed the absence of specific monitoring orders or tasks related to the anticoagulant therapy.
A resident with a Stage 3 pressure ulcer did not have wound treatments consistently documented as administered, with fifteen days of missing entries in the ETAR despite active physician orders. Nursing staff interviews revealed that treatments may have been performed but were not always recorded, especially during busy times or on weekends. The DON confirmed the expectation for complete documentation and acknowledged the missing records.
Staff did not follow hand hygiene protocols during medication administration and wound care. An LPN failed to wash or sanitize hands before and after administering medications to two residents, and a nurse did not change gloves or perform hand hygiene between the dirty and clean steps of a wound care procedure for a resident with chronic kidney disease and dementia. These actions were not in accordance with facility policies.
A facility failed to complete and submit a Discharge Tracking MDS assessment for a resident transferred to a behavioral health center. The MDS Nurse missed the assessment due to a transition to a new charting system. The resident, admitted with senile degeneration of the brain, did not have the required assessment completed, as confirmed by the DON.
The facility failed to implement a care plan for a resident with Hemiplegia/Hemiparesis, neglecting oral and nail care, as observed by an LPN and confirmed by the DON. Additionally, the facility did not develop an individualized care plan for a resident with PTSD, failing to address potential triggers and fears. Interviews with staff revealed the absence of a trauma-informed care assessment, leading to a lack of specific interventions for the resident's needs.
A resident with Parkinson's Disease and other health issues was found with inadequate oral and nail care, as observed by surveyors. The facility's policies for daily oral hygiene and nail care were not followed, resulting in a yellow substance on the resident's teeth and debris under his fingernails. The LPN and DON confirmed the neglect, acknowledging that CNAs were responsible for these tasks.
A facility failed to complete a Trauma Informed Care Assessment for a resident with PTSD, despite the resident's documented history of traumatic events and a prescription for Zoloft. The resident was cognitively intact, and staff interviews confirmed awareness of the PTSD diagnosis. However, the facility's social assessment inaccurately stated no traumatic history, and the necessary assessment was not conducted to address symptoms and triggers.
Failure to Care Plan Newly Identified Sacral Skin Breakdown
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and time frames for a newly identified excoriated area on the sacrum of one resident. Facility policy titled “Care Plan Process,” revised 12/24, requires that care plans include measurable objectives, time frames, and descriptions of services to attain or maintain each resident’s highest practicable well-being, and that care plans be reviewed and revised on an ongoing basis. Record review of the Care Plan Report for Resident #1 showed no care plan addressing the excoriated sacral area, despite Progress Notes dated 2/15/26 documenting the presence of a new excoriated area to the sacrum requiring treatment and monitoring. The resident’s face sheet indicated admission on 5/22/2019 with diagnoses including Diabetes Mellitus and Cerebral Infarction. In interviews, an RN stated that the purpose of the care plan was to ensure staff knew how to care for the resident, and the MDS Nurse confirmed that no care plan had been developed for the new skin breakdown and acknowledged that one should have been implemented. This deficiency reflects the facility’s failure to follow its own care plan policy and to create a care plan for the resident’s newly identified sacral skin breakdown, despite documented need for treatment and monitoring and staff acknowledgment of the care plan’s role in guiding resident care.
Failure to Provide Ordered Sacral Skin Treatment Due to Order Entry Error
Penalty
Summary
The facility failed to provide ordered treatment for a resident who developed an excoriated, slightly reddened area on the sacrum. According to the facility’s policy on Prevention and Treatment of Skin Issues, residents at risk for impaired skin integrity and pressure ulcers are to be properly identified, assessed, and provided appropriate treatment modalities. Progress notes documented that on 2/15/26 a CNA notified an RN of the skin issue, the RN assessed the resident, identified the excoriated sacral area with no drainage, notified the DON, wound care nurse, and responsible party, and obtained an order to cleanse the area with wound cleanser, pat dry, and apply zinc oxide every shift until healed. Record review of the Medication Administration Record and Treatment Administration Record for February 2026 showed no documentation that the ordered sacral treatment was ever provided. During interview and concurrent record review, the RN confirmed there was no documentation of the treatment and stated she did not know why the treatment had not triggered on the MAR/TAR, agreeing that failure to perform the treatment could have caused worsening of the area. The DON stated that although daily review of orders is conducted, the treatment order was missed and did not trigger to the MAR/TAR because an incorrect order type was selected when the order was entered on 2/15/26. The resident, who had diagnoses including diabetes mellitus and cerebral infarction and had been admitted in 2019, was later sent to the emergency department for a change in level of consciousness and did not return, with discharge documented on 2/25/26.
Resident Subjected to Physical and Verbal Abuse by Staff Member
Penalty
Summary
A deficiency occurred when a staff member, Nurse Aide (NA) #1, engaged in abusive conduct toward a resident with moderate cognitive impairment and a history of hemiplegia and hypertensive urgency. The incident involved the aide pulling the resident from a seated position onto the floor, verbally berating him, and spraying him with an aerosol substance. Multiple staff and resident interviews confirmed that the aide entered the resident's room, expressed frustration, and proceeded to remove a pillow from under the resident, causing him to fall. While the resident was on the floor, the aide continued to yell at him to get up and sprayed his lower body with an aerosol spray, which was believed to be disinfectant or air freshener. Witnesses, including housekeeping staff and another CNA, reported hearing the resident scream for help and observed the aide laughing and continuing the abusive behavior. The resident expressed fear for his life and distress over the incident, stating he was shaken and scared by the aide's actions. Staff members who entered the room found the resident on the floor and the aide sitting in a chair, laughing, and continuing to spray the resident and throw his belongings into the garbage can. Despite conflicting accounts from some staff regarding the intent and details of the incident, the totality of evidence from interviews and witness statements substantiated that abuse did occur. The resident experienced actual psychosocial harm, including fear, distress, and compromised dignity as a result of the aide's actions. The facility's failure to protect the resident from all forms of abuse constituted a violation of regulatory requirements.
Failure to Thoroughly Investigate Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving one resident. The incident occurred when staff responded to the resident screaming for help and found the resident on the floor after an altercation with a nurse aide. The resident reported that the nurse aide pulled a pillow from under them, causing them to fall, and then sprayed them with disinfectant spray. Witness statements from housekeeping and other staff corroborated that the nurse aide was laughing, yelling at the resident, and spraying their legs with an aerosol substance. Multiple staff members wrote witness statements and submitted them to administration. Despite these accounts, the facility's abuse investigation did not include the witness statements from the staff in the documentation. The administrator determined the allegation could not be substantiated due to an inability to prove intent and conflicting accounts, but acknowledged that the determination was not supported by the totality of evidence. The resident involved had a history of moderate cognitive impairment and other medical conditions. The facility's actions did not align with its policy to thoroughly investigate all alleged violations.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, resulting in deficiencies related to care planning. For one resident prescribed an anticoagulant (Apixaban) for acute embolism and thrombosis, there was no care plan addressing the risks associated with anticoagulant therapy, such as monitoring for bleeding. This omission was confirmed by both the MDS Coordinator and the DON, who acknowledged that a care plan should have been initiated when the medication order was entered. The resident was cognitively intact at the time of the deficiency. For another resident with Parkinson's Disease and dyskinesia, the facility failed to implement the care plan for Activities of Daily Living (ADLs), specifically regarding bathing and showering assistance. The resident, also cognitively intact, reported not having received a bath or shower since admission, and was observed to have a foul odor. The care plan indicated the need for partial/moderate assistance with bathing, but this intervention was not carried out as documented.
Failure to Provide Scheduled Bathing Assistance and Documentation
Penalty
Summary
A deficiency occurred when a resident who required assistance with activities of daily living, specifically bathing, did not receive the necessary care. The facility's policy required CNAs to document daily ADL care, including bathing, as a permanent part of the resident's chart. However, observations revealed that the resident had a foul odor and was wearing the same clothing on consecutive days. The resident and his brother, who is also his roommate, both reported that the resident had not received a bath or shower since admission two weeks prior. Staff interviews confirmed uncertainty about when the resident last received a bath or shower, and documentation of bathing was absent from the resident's records for the relevant period. The resident was admitted with diagnoses including Parkinson's Disease and was assessed as cognitively intact with a BIMS score of 15. Despite being scheduled for baths on Mondays, Wednesdays, and Fridays, there was no evidence that these were provided. Both CNA and LPN staff were unable to recall or provide documentation of bathing, and the DON confirmed the resident should have received scheduled baths. The lack of documented and observed bathing care constituted a failure to provide required assistance with ADLs for this resident.
Failure to Maintain Homelike Resident Environment Due to Unrepaired Wall Damage
Penalty
Summary
The facility failed to provide a homelike environment for one resident, as evidenced by a large area of missing paint, approximately two feet by four feet, on the wall in the resident's room across from the bathroom door. The resident, who has moderate cognitive impairment as indicated by a BIMS score of 12, expressed concern about the appearance of the room, noting that it had been in that condition since admission and that it was not acceptable for family visits. The Maintenance Director acknowledged awareness of the issue but had not addressed it, and the Administrator admitted to not noticing the problem during rounds. Facility policy requires maintaining a safe, clean, and homelike environment, which was not upheld in this instance.
Inaccurate MDS Coding of Bed Rails as Restraint
Penalty
Summary
The facility failed to accurately code an admission Minimum Data Set (MDS) assessment for one resident. Specifically, the MDS assessment for a resident with a history of traumatic hemorrhage of the left cerebrum and severe cognitive impairment was incorrectly coded to indicate that bed rails were being used as a restraint. However, the resident's care plan documented that the side rails were in place for bed mobility and positioning, not as a restraint. Observation confirmed the presence of half side rails on the resident's bed. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing (DON), confirmed that the bed rails were not intended as restraints but rather to assist with positioning. Both staff members acknowledged the error in the MDS coding, with the DON emphasizing that the facility does not use restraints. The deficiency was identified through a review of facility policy, resident records, staff interviews, and direct observation.
Failure to Monitor for Adverse Effects of Anticoagulant Medication
Penalty
Summary
The facility failed to monitor for adverse effects of an anticoagulant medication for one resident who was prescribed Apixaban for acute embolism and thrombosis of the femoral vein. Review of the resident's physician orders, medication administration record, and treatment administration record revealed that there was no monitoring protocol in place to observe for side effects associated with anticoagulant therapy, such as bleeding or excessive bruising. The facility's policy required observation for adverse effects and physician notification if any occurred, but this was not implemented for the resident in question. Interviews with staff, including an LPN, the MDS Coordinator, and the DON, confirmed that there were no specific orders or monitoring tasks in place to assess for bleeding risks related to the anticoagulant medication. Staff emphasized the importance of such monitoring and acknowledged its absence, noting that monitoring should begin whenever an anticoagulant is prescribed. The resident involved was cognitively intact and had been admitted with a diagnosis of acute embolism and thrombosis.
Failure to Document Wound Treatments for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to document wound treatments as ordered for a resident with a Stage 3 pressure ulcer. Review of the Electronic Treatment Administration Record (ETAR) for this resident revealed multiple instances across April, May, and June where wound care treatments were not documented as administered, despite active physician orders. Specifically, there were fifteen days with missing documentation for wound care treatments, including cleaning, application of medications, and dressing changes. Interviews with nursing staff indicated that while treatments may have been performed, documentation was not consistently completed in the ETAR. The Director of Nursing confirmed the expectation that all treatments should be documented and acknowledged the missing entries. The resident involved had a history of chronic kidney disease and dementia and was rarely or never understood, according to the Minimum Data Set. The wound was observed to have pink granulation tissue at the time of survey, and staff interviews indicated that wound management services were provided weekly. However, both the treatment nurse and other nursing staff admitted to occasional lapses in documentation, particularly during busy periods or on weekends, leading to incomplete records of wound care provided.
Failure to Perform Proper Hand Hygiene During Medication Administration and Wound Care
Penalty
Summary
Staff failed to perform proper hand hygiene during three of nine direct care observations, as required by facility policy. Specifically, an LPN did not wash or sanitize her hands before setting up or administering medications to two residents, nor did she perform hand hygiene between medication administrations. The LPN acknowledged not following hand hygiene protocols and indicated a lack of immediate access to hand sanitizer on her medication cart. Additionally, a registered nurse did not change gloves or perform hand hygiene between the dirty and clean steps of a wound care procedure for a resident with chronic kidney disease and dementia. The RN removed soiled dressings, cleaned the wound, and applied new dressings without changing gloves or washing hands between steps, which was confirmed during an interview. Facility policies reviewed required hand hygiene between resident contacts and during wound care procedures, but these were not followed during the observed incidents.
Failure to Complete Discharge Tracking MDS Assessment
Penalty
Summary
The facility failed to complete and submit a Discharge Tracking Minimum Data Set (MDS) resident assessment to the Centers for Medicare and Medicaid Services (CMS) for a resident who was transferred to an acute care facility. This deficiency was identified for one of the 16 MDS assessments reviewed, specifically for Resident #38. The facility's policy, titled MDS Process, outlines the requirements for MDS coding guidelines, time schedules, and requirements, which were not adhered to in this case. Resident #38 was transferred to a behavioral health center and returned to the facility, but the discharge tracking assessment was not completed. The Director of Nursing (DON) confirmed that the assessment was not done, and the MDS Nurse admitted to missing the assessment due to the facility transitioning to a new charting system at the time. Resident #38 was admitted to the facility with a diagnosis of senile degeneration of the brain.
Deficiencies in Care Planning for Residents with Specific Needs
Penalty
Summary
The facility failed to implement a care plan for nail and oral care for Resident #31, who has a diagnosis of Hemiplegia/Hemiparesis on the right side. Observations on two consecutive days revealed that Resident #31 was lying in bed with a yellow substance covering his teeth and a brown substance under the fingernails of his left hand. The Licensed Practical Nurse (LPN) confirmed the presence of the yellow buildup on the resident's teeth, which could lead to tooth decay and other oral health issues. The Director of Nursing (DON) acknowledged that the staff did not follow the care plan, resulting in the neglect of oral and nail care for Resident #31. Additionally, the facility failed to develop an individualized comprehensive care plan for Resident #37, who has a diagnosis of Post Traumatic Stress Disorder (PTSD). The care plan did not address potential triggers, fears, or behavioral expressions related to the resident's history of trauma. Interviews with the Social Services staff and LPN revealed that Resident #37 exhibited inappropriate touching behaviors and did not like to be hugged. The DON confirmed that a comprehensive care plan was not developed due to the absence of a completed trauma-informed care assessment, and the Minimum Data Set (MDS) Nurse confirmed that the care plan was not individualized to address the resident's specific needs related to PTSD.
Failure to Provide Adequate Oral and Nail Care
Penalty
Summary
The facility failed to provide adequate oral and nail care for a resident, as observed during a survey. The facility's policies for oral hygiene and nail care were not followed, resulting in a resident being found with a yellow substance covering his teeth and a brown substance under the fingernails of his left hand. The Licensed Practical Nurse (LPN) confirmed that the resident's mouth care had not been performed, and the Certified Nursing Assistants (CNAs) were responsible for this task. The LPN also acknowledged the presence of debris under the resident's fingernails and stated that nail care should be checked daily, although it was scheduled weekly. The Director of Nursing (DON) confirmed that mouth care was supposed to be completed at least once a day and that CNAs were responsible for both oral and nail care. The DON expressed dissatisfaction with the failure to provide these essential care activities, acknowledging that such neglect could lead to health issues. The resident involved had a medical history including Parkinson's Disease, Dysphagia following Cerebral Infarction, and Cognitive Communication Deficit, which may have contributed to his inability to perform these activities of daily living independently.
Failure to Complete Trauma Informed Care Assessment for Resident with PTSD
Penalty
Summary
The facility failed to complete a Trauma Informed Care Assessment for a resident diagnosed with Post Traumatic Stress Disorder (PTSD). The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, had a documented history of traumatic events and was prescribed Zoloft for PTSD symptoms following a behavioral health stay. Despite this, the facility's social assessment inaccurately stated that the resident had not experienced any traumatic events or trauma-related symptoms. Interviews with facility staff, including Social Services and the Director of Nursing, confirmed the absence of a trauma informed care assessment for the resident. The social services staff acknowledged awareness of the resident's traumatic history but had not completed the necessary assessment. Additionally, the Licensed Practical Nurse caring for the resident was aware of the PTSD diagnosis and noted the resident's aversion to physical contact, such as hugging. The Director of Nursing confirmed that the assessment should have been conducted to address the resident's symptoms and potential triggers.
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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