The Bluffs Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Vicksburg, Mississippi.
- Location
- 2850 Porter's Chapel Road, Vicksburg, Mississippi 39180
- CMS Provider Number
- 255140
- Inspections on file
- 22
- Latest survey
- April 21, 2026
- Citations (last 12 mo.)
- 4 (1 serious)
Citation history
Health deficiencies cited at The Bluffs Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A cognitively impaired resident with a history of cerebral infarction, right-sided hemiplegia, and a documented moderate risk for wandering was able to leave a supervised front porch area without staff awareness, propel a wheelchair down the facility driveway, and cross a heavily trafficked road into an area with a steep ditch and wooded terrain. Staff interviews showed that the resident was usually outside with other residents and staff present, but on the day of the incident a CNA last saw the resident on the porch and was unsure how the resident exited unsupervised. The resident was ultimately discovered by a CNA who had been alerted by a pest control worker, by which time the resident had already crossed the roadway, demonstrating a failure to provide adequate supervision and prevent elopement for a cognitively impaired individual.
A resident with a gastrostomy and PEG tube was under Enhanced Barrier Precautions (EBP), as indicated by facility policy and signage requiring staff to wear gloves and a gown during high-contact care, including feeding tube care and use. An LPN was observed administering medications via the resident’s PEG tube without donning a gown, despite the posted EBP instructions. In interviews, the LPN acknowledged understanding that EBP are used to prevent infection and agreed a gown should have been worn, and the DON confirmed the expectation that a gown be used for PEG tube medication administration under EBP.
A resident's baseline care plan and bedside Kardex lacked documentation of transfer needs, despite the individual being dependent and requiring a total lift. This omission led to a transfer-related injury, as staff were not informed of the correct transfer method. Staff interviews and record reviews confirmed the absence of this critical information.
A resident assessed as dependent for transfers was manually moved from bed to wheelchair by two staff members without the required mechanical lift, despite being informed by the resident and her representative that a lift was necessary. During the transfer, the resident slipped and sustained a traumatic laceration to her right leg after striking exposed metal on the wheelchair. Staff did not consult the nurse supervisor or question the transfer method, and the resident's transfer status was not clearly communicated on the Kardex.
A resident with dementia was found restrained to her bed with sheets tied across her chest and legs by an LPN, violating the facility's restraint-free policy. The incident was reported by staff who removed the restraints and notified the DON. The LPN admitted to using the sheets to prevent the resident from getting up unassisted, despite denying they were used as restraints. The resident was unharmed, and the LPN was terminated following an investigation.
The facility failed to provide RN coverage for eight hours on a specific day, as required by policy. The DON scheduled an RN who had requested the day off and did not cover the shift herself, resulting in a staffing deficiency. No incidents or IV therapy occurred on that day.
The facility failed to submit accurate staffing data into the PBJ system for the fourth quarter of 2024. The policy requires staffing data to include daily hours worked by each staff member. However, the PBJ Staffing Data Report revealed excessively low weekend staffing. The Administrator and DON confirmed the data was incorrect due to employees not clocking out and in for weekend mealtimes, affecting weekend hours.
The facility failed to provide written transfer notifications to residents or their representatives for hospital transfers, as required by policy. This deficiency affected three residents, including one who is cognitively intact and his own responsible party. The Social Services Director admitted to not sending these notifications, and the Administrator confirmed the oversight.
The facility failed to provide written bed-hold notifications to residents or their representatives following hospital transfers, as required by their policy. This deficiency affected three residents, including one with End Stage Renal Disease and another with Malignant Neoplasm of Glottis. Interviews revealed a lack of awareness and implementation of the policy by Social Services and the Administrator.
A facility failed to follow proper hand hygiene protocols during wound care for a resident with a Stage 4 pressure ulcer. An RN did not change gloves or wash hands between dirty and clean procedures, which was confirmed by the DON as a breach of infection control policy. This lapse could potentially lead to infection and delay healing.
The facility failed to implement comprehensive care plans for personal hygiene for three residents, leading to deficiencies in grooming and hygiene. A resident with diabetes was found with long, dirty fingernails and facial hair, while another resident with dementia was lying in a urine-saturated bed with significant facial hair growth. A third resident was observed with long facial hair and dirty fingernails. The DON confirmed the care plans were not followed, and the MDS Coordinator admitted there was no excuse for the lack of care.
A resident reported verbal abuse by a CNA, who threatened to run him over with her truck after he refused to throw something away. Witnesses confirmed the threat and observed the CNA backing up her vehicle while the resident was behind it. The resident, who is cognitively intact and has a spinal cord injury, reported the incident, leading to the CNA's suspension and an investigation that substantiated the abuse.
A resident in a LTC facility did not receive a shower, shave, or hair brushing for over two weeks despite expressing a preference for a shower upon admission. Observations showed the resident's hair and beard were unkempt, and fingernails were long with a dark substance underneath. Interviews with staff revealed no set shower schedule, and the Director of Nursing acknowledged the issue, recognizing it as a failure to honor the resident's right of choice.
The facility failed to maintain a homelike environment as broken blinds in several resident rooms compromised privacy. Observations revealed missing or broken slats in rooms, and staff interviews indicated a lack of formal documentation for maintenance needs. The Administrator and Maintenance Director were aware of the issue, but no actions were documented to address it.
A facility failed to implement a baseline care plan for a resident's personal hygiene preferences and needs. Despite the resident's preference for showers and requirement for assistance, he did not receive a shower, shave, or hair brushing since admission. The MDS Coordinator confirmed the care plan was not followed, leading to the deficiency.
The facility failed to provide adequate personal hygiene and grooming for four residents, resulting in deficiencies in their care. A resident was found with long, jagged fingernails and facial hair, while another was lying in a urine-saturated bed with a strong odor. Two other residents experienced similar neglect, with one not receiving a shower or grooming since admission. The facility lacked a shower schedule, and the DON acknowledged the issue of inadequate care.
A facility failed to accurately complete the MDS assessment for a resident by incorrectly coding anticoagulant medication usage. The MDS indicated the resident received anticoagulant medication for seven days, but the eMAR showed no such medication was administered during the observation period. The MDS Coordinator confirmed the error, noting the resident was not on anticoagulant medication. The resident had diagnoses including Type 2 Diabetes Mellitus, Chronic Pulmonary Edema, and Heart Failure.
Failure to Supervise Cognitively Impaired Resident Resulting in Elopement into Hazardous Area
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain an environment free from accident hazards for a cognitively impaired resident who exited the building and traveled into an uncontrolled, hazardous area without staff awareness. The facility had a policy titled "Wanderer Management, Monitoring System and Resident Elopement Protocol" which stated that all residents would be afforded adequate supervision to provide the safest environment possible. Despite this policy, a resident with a documented moderate risk for wandering and moderate cognitive impairment was able to leave the supervised area of the front porch, travel down the facility driveway, and cross a heavily trafficked road before staff intervened. Record review showed that the resident had been admitted with diagnoses including cerebral infarction and hemiplegia/hemiparesis affecting the right dominant side. A Nex-Wander Data Collection form dated several months prior documented a score of seven, indicating a moderate risk for wandering. A BIMS assessment completed on the date of the incident showed a score of nine, indicating moderate cognitive impairment. Staff interviews revealed that the resident was typically on the front porch with other residents who smoked and drank coffee, and staff were usually present. On the day of the incident, a CNA reported seeing the resident on the front porch in a wheelchair drinking water shortly after 3:00 PM, but there was uncertainty about how the resident got outside and whether he may have followed another resident. At approximately 3:32 PM, a CNA who was leaving the facility was informed by a pest control representative that a resident in a wheelchair was heading toward the bottom of the driveway. By the time the CNA reached the resident, he had propelled his wheelchair down the driveway and across the facility drive into a grassy area, and the CNA observed him continue across the street despite attempts to get him to stop. The route later observed by the surveyor showed that the resident had traveled about one-half mile down the driveway and across a heavily trafficked road, where environmental hazards included a steep ditch and wooded area. The facility’s Interim DON confirmed that the resident had not previously wandered or attempted elopement. The State Agency determined that this lack of supervision and failure to prevent the resident’s unsupervised exit into a hazardous environment constituted noncompliance at F689 at an Immediate Jeopardy level, likely to cause serious injury, harm, impairment, or death.
Failure to Follow Enhanced Barrier Precautions During PEG Tube Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to implement its Enhanced Barrier Precautions (EBP) policy during PEG tube medication administration for one resident. The facility’s EBP policy, last reviewed on 6/30/25, defined EBP as an infection control intervention requiring targeted gown and glove use during high-contact resident care activities, and specified that EBP are indicated for residents with indwelling medical devices, including feeding tubes. Signage posted outside the resident’s room indicated that EBP were in effect and instructed providers and staff to wear gloves and a gown during high-contact resident care activities, including device care and use involving a feeding tube. On the survey date at 9:00 AM, an LPN was observed administering medications via the resident’s Percutaneous Endoscopic Gastrostomy (PEG) tube without donning a gown, contrary to the posted EBP instructions and facility policy. The resident had been admitted on 11/17/25 with diagnoses including an encounter for attention to gastrostomy, indicating the presence of a feeding tube. In a subsequent interview at 9:25 AM, the LPN stated that EBP were used to prevent the spread of infection, acknowledged that she did not wear a gown while administering the PEG tube medications, and agreed that she should have worn one. At 10:00 AM, the DON confirmed that her expectation was that the LPN would have worn a gown when administering medications through a PEG tube in accordance with EBP.
Failure to Document and Communicate Resident Transfer Needs on Baseline Care Plan
Penalty
Summary
The facility failed to complete a baseline care plan that included the minimum healthcare information necessary to provide effective, person-centered care for a newly admitted resident. Specifically, the baseline care plan and the bedside Kardex did not document the resident's transfer needs, despite the resident being dependent and requiring a total lift for transfers. This omission was confirmed through staff interviews and record reviews, which showed that the resident's transfer status was not assessed or communicated to staff at the time of admission. As a result of this incomplete documentation, the resident's transfer needs were not identified or communicated, leading to an incident where the resident sustained a laceration during a transfer from bed to chair. The injury was classified as a trauma injury and measured 4.5 cm by 5.5 cm by 0.2 cm. Staff interviews confirmed that the information regarding the resident's dependency and need for a total lift was not available on the Kardex or baseline care plan, and staff should have consulted the nurse supervisor for clarification.
Failure to Use Required Lift Results in Resident Injury During Transfer
Penalty
Summary
The facility failed to ensure a resident was transferred safely in accordance with her assessed needs, resulting in a traumatic injury. Despite the resident being assessed as dependent for transfers and requiring a total lift, two staff members performed a manual transfer from bed to wheelchair without using the mechanical lift. The resident and her representative both informed staff that a lift was required, but staff proceeded to manually slide the resident, during which her legs and torso slipped downward and her right leg struck the exposed metal of the wheelchair armrest slot, causing a laceration. Staff involved in the transfer acknowledged not questioning the presence of a sling pad in the wheelchair and did not consult the nurse supervisor for clarification. The resident, who was cognitively intact and had a diagnosis of alcoholic cirrhosis of the liver with ascites, sustained a trauma laceration to her right leg, measured at 4.5 cm x 5.5 cm x 0.2 cm, as confirmed by the treatment nurse. The facility's policy required the licensed nurse to determine and communicate the level of assistance needed for safe transfers, but the resident's transfer status was not reflected on the Kardex for staff reference. The risk manager confirmed that the resident was not transferred according to her assessed needs and acknowledged that this failure could lead to accidents.
Resident Restrained with Sheets in Violation of Restraint-Free Policy
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, as evidenced by an incident involving a resident diagnosed with unspecified dementia. The resident was admitted to the facility on December 5, 2024. On February 18, 2025, an allegation was reported that the resident was found restrained to her bed with sheets tied across her chest and legs. This was observed by a Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA), who immediately removed the restraints and reported the incident to the Director of Nursing (DON). The investigation revealed that the resident had been restrained for approximately five minutes by an LPN, who admitted to securing the sheets to prevent the resident from getting up unassisted, citing concerns about falls and the resident's previous attempts to ambulate without assistance. Despite the LPN's denial of using the sheets as restraints, witness statements and staff interviews confirmed that the resident was indeed tied to the bed, which constituted a violation of the facility's restraint-free policy. The facility's policy on personal safety devices clearly states that residents have the right to be free from physical restraints imposed for discipline or convenience. The incident was substantiated, and the LPN involved was terminated following the investigation. The resident was found to have no injuries from the incident, and the facility took immediate steps to address the situation and ensure compliance with their restraint-free policy.
Failure to Provide RN Coverage for Required Hours
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) for eight consecutive hours on one of the 14 staffing days reviewed, specifically on December 25th. According to the facility's policy, an RN must be on duty for at least eight hours every day to handle emergencies and intravenous medications. However, on the specified date, there was no RN coverage. The Director of Nurses (DON) confirmed that the scheduled RN did not show up, and she was not notified of the absence until later in the day. The DON admitted that she did not come in to cover the shift, citing that everyone else was on vacation and agency RNs were not allowed for coverage. The Administrator confirmed the lack of RN coverage and stated that the DON had scheduled an RN who had already requested the day off. The DON acknowledged that she was responsible for the scheduling and was unaware of the RN's request for time off. Despite being informed by the RN about the prior request, the DON did not ensure coverage for the shift. There were no reported incidents or intravenous therapy needs on that day, but the absence of an RN was a violation of the facility's staffing policy.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to submit accurate staffing data into the Payroll-Based Journal (PBJ) system for the fourth quarter of 2024. The facility's policy, titled 'Reporting Direct-Care Staffing Information (Payroll-Based Journal)' dated October 2022, requires staffing data to include the number of hours worked each day by each staff member. However, a review of the PBJ Staffing Data Report CASPER for Fiscal Year Quarter 4 2024 revealed excessively low weekend staffing, indicating that the submitted weekend staffing data was excessively low. During an interview, the Administrator and the Director of Nurses (DON) confirmed that the data entered for the fourth quarter PBJ was incorrect and did not capture the full direct care hours. The DON disclosed that the issue arose from employees failing to clock out and in for weekend mealtimes, which affected their overall weekend hours.
Failure to Provide Written Transfer Notifications
Penalty
Summary
The facility failed to provide written transfer or discharge notifications to residents or their representatives for hospital transfers, as required by their policy. This deficiency was identified for three residents during a review of records and interviews with staff and residents. The facility's policy, last reviewed on 5/17/24, mandates that residents and their representatives receive written notification detailing the specific reasons for transfers. However, the Social Services Director admitted to not sending these notifications, indicating a lack of awareness of this requirement. Resident #8 was transferred to a hospital on 8/22/24 without receiving a written notification. Similarly, Resident #27, who is cognitively intact and his own responsible party, was transferred multiple times without receiving any written notifications. Resident #45 also experienced multiple hospital transfers without written notifications. Interviews with the Social Services Director and the Administrator confirmed the oversight, with the Administrator expressing an expectation that the Social Services Director should have provided the necessary notifications.
Failure to Provide Bed-Hold Notifications
Penalty
Summary
The facility failed to provide written bed-hold notifications to residents or their representatives following hospital transfers, as required by their policy. This deficiency was identified through staff and resident interviews, record reviews, and a review of the facility's policy titled 'Transfer or Discharge Documentation and Notice.' The policy mandates that residents and their representatives be notified in writing about the facility's bed-hold policy during transfers to a hospital or therapeutic leave. However, for three residents reviewed, no such notifications were provided. Resident #8, who was admitted with End Stage Renal Disease and Diastolic Congestive Heart Failure, was transferred to a hospital without receiving a bed-hold notice. Similarly, Resident #27, who is cognitively intact and responsible for his own decisions, was transferred multiple times without receiving the required notification. Resident #45, admitted with a diagnosis of Malignant Neoplasm of Glottis, also did not receive a bed-hold notice during hospital transfers. Interviews with Social Services and the Administrator revealed a lack of awareness and implementation of the policy, leading to the deficiency.
Inadequate Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to adhere to its infection prevention and control program, specifically in the area of hand hygiene during wound care. During an observation, a Registered Nurse (RN) was seen providing wound care to a resident with a Stage 4 pressure ulcer in the sacral region. The RN washed her hands and applied clean gloves after removing the resident's wound bandage. However, after cleaning the wound and applying Santyl ointment, the RN did not change her gloves or wash her hands between the dirty and clean procedures. This lapse in proper hand hygiene was confirmed by the RN and acknowledged as a potential cause of infection. The Director of Nurses (DON) confirmed that the facility's policy requires changing gloves and washing hands between dirty and clean wound treatment procedures. The failure to follow this policy was recognized as an infection control issue that could delay the healing process. The resident involved was admitted with a diagnosis that included a Stage 4 pressure ulcer of the sacral region, highlighting the critical need for stringent infection control practices to prevent further complications.
Failure to Implement Comprehensive Care Plans for Personal Hygiene
Penalty
Summary
The facility failed to implement comprehensive care plans for personal hygiene for three residents, leading to deficiencies in their grooming and hygiene. Resident #17, who is cognitively intact and has medical diagnoses including Type 2 Diabetes Mellitus, was observed with long, jagged fingernails with a brown substance underneath and long facial hair. The Director of Nurses (DON) confirmed that the resident's grooming needs were not met, as the nurses are responsible for nail care due to the resident's diabetes, and facial hair trimming is part of daily grooming. Resident #49, diagnosed with Unspecified Dementia and other conditions, was found lying in a bed saturated with urine, emitting a strong odor, and with significant facial hair growth. The Certified Nursing Assistant (CNA) confirmed the resident had not been changed by the night shift, and the DON acknowledged that the resident's hygiene plan was not followed. This indicates a failure in executing the care plan, which required the resident to be dependent on staff for personal hygiene and toileting. Resident #57, with a history of confusion and impaired balance, was observed with long facial hair and dirty, jagged fingernails. The DON confirmed the resident was not properly groomed, and the MDS Nurse stated that the care plans were not followed. The care plan required the resident to be dependent on staff for personal hygiene, including nail care due to diabetes. The MDS Coordinator admitted there was no excuse for the residents not receiving the care specified in their care plans.
Verbal Abuse Incident Involving CNA and Resident
Penalty
Summary
The facility failed to protect a resident from verbal abuse, as evidenced by an incident involving a Certified Nursing Assistant (CNA) and a resident. On the morning of September 8, 2024, the resident reported that CNA #5 made a verbal threat towards him after he refused to throw something in the trash for her. The resident stated that CNA #5 threatened to run him over with her truck, and witnesses corroborated that she backed up her vehicle, screeched her tires, and left the parking lot while the resident was behind her in his motorized wheelchair. The facility's investigation substantiated the occurrence of verbal abuse. The resident involved, identified as Resident #60, was admitted to the facility with an unspecified injury at the T2-T6 level of the thoracic spinal cord and was cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 15. The incident was reported to the facility's administrator, who confirmed the details and suspended CNA #5 pending investigation. The facility's policy on the prohibition of abuse, neglect, and misappropriation of property emphasizes the residents' right to be free from abuse, mistreatment, and neglect, which was violated in this case.
Failure to Honor Resident's Shower Preferences
Penalty
Summary
The facility failed to honor a resident's preferences, specifically for Resident #195, who had been in the facility for over two weeks without receiving a shower, shave, or hair brushing, despite expressing his preference for a shower upon admission. Observations revealed that the resident's hair and beard were unkempt and matted, and his fingernails were long with a dark brown substance underneath. The resident, who was unable to shower himself due to mobility issues, had repeatedly requested a shower from the staff, but his requests were not fulfilled. Interviews with facility staff, including CNAs and the Director of Nursing, confirmed that there was no set shower schedule in place, and the resident's shower had not been documented since admission. The Director of Nursing acknowledged the lack of a shower schedule and admitted awareness of the issue, recognizing it as a failure to honor the resident's right of choice. The resident's cognitive status was intact, as indicated by a BIMS score of 13, and he had expressed that choosing a bath or shower was very important to him.
Facility Fails to Maintain Homelike Environment Due to Broken Blinds
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment as evidenced by broken blinds or window coverings in several resident rooms. During a survey, it was observed that rooms 203, 505, 601, and 607 had broken or missing slats on window blinds, which compromised the privacy of the residents as the rooms were visible from outside the building. The facility's policy on maintaining a homelike environment was not adhered to, as the broken blinds were not promptly repaired or replaced. Interviews with staff revealed a lack of formal documentation and communication regarding maintenance needs. A Certified Nursing Assistant (CNA) acknowledged the broken blinds but admitted to forgetting to report the issue due to other responsibilities. The Administrator and Maintenance Director were aware of the problem, with the Administrator conducting daily rounds and the Maintenance Director confirming the arrival of replacement blinds. However, there was no documentation of maintenance requests or actions taken to address the issue, leading to the deficiency in maintaining a homelike environment for the residents.
Failure to Implement Baseline Care Plan for Resident's Hygiene Needs
Penalty
Summary
The facility failed to implement a baseline care plan for a resident, specifically regarding preferences and personal hygiene care. The baseline care plan, dated 12/21/24, indicated that the resident preferred showers and required assistance with bathing and personal hygiene. However, an observation and interview with the resident on 1/6/25 revealed that he had not received a shower, shave, or hair brushing since his admission, despite expressing his preferences to the staff during admission. The resident's hair was matted, and his fingernails were unkempt, indicating a lack of personal hygiene care. The Minimum Data Set (MDS) Coordinator confirmed that the care plan was not implemented as the staff did not provide the necessary assistance with bathing and personal hygiene, which was required to meet the resident's needs. The resident, who was admitted with a diagnosis of Acute Kidney Failure, was cognitively intact with a BIMS score of 13. The MDS assessment indicated that the resident required substantial assistance with showering and supervision or touching assistance for personal hygiene, which was not provided, leading to the deficiency.
Deficiencies in Personal Hygiene and Grooming
Penalty
Summary
The facility failed to provide adequate personal hygiene and grooming for four residents, leading to deficiencies in their care. Resident #17 was observed with long, jagged fingernails and facial hair, which had not been attended to despite the resident's request for grooming. The Director of Nurses (DON) confirmed that the nurses were responsible for trimming the resident's nails due to her diabetes, and the lack of grooming could lead to skin concerns. The Licensed Practical Nurse (LPN) admitted to not having a set schedule for nail care, resulting in the resident's neglected appearance. Resident #49 was found lying in a urine-saturated bed with a strong odor, indicating that he had not been changed for a significant period. The CNA assigned to him admitted to not changing his brief due to being busy with other tasks, and the DON acknowledged the issue of inadequate care. Additionally, the resident had not been groomed, with noticeable facial hair growth, which was confirmed by the Administrator as unacceptable. Resident #57 and Resident #195 also experienced similar neglect in personal hygiene. Resident #57 had long, dirty fingernails and unshaven facial hair, with the DON confirming the lack of grooming. Resident #195, who had been in the facility for over two weeks, reported not receiving a shower or grooming since admission. The facility lacked a shower schedule, and the DON admitted to being aware of the problem but had not implemented a solution. These observations highlight the facility's failure to adhere to its policy on supporting activities of daily living, resulting in inadequate care for the residents.
Inaccurate MDS Coding for Anticoagulant Use
Penalty
Summary
The facility failed to accurately complete Section N of the Minimum Data Set (MDS) assessment for a resident, specifically regarding the coding of anticoagulant medication usage. During the 7-day observation look-back period, the MDS indicated that the resident received anticoagulant medication for seven days. However, a review of the Electronic Medication Administration Record (eMAR) revealed that the resident did not receive any anticoagulant medication during this period. An interview with the MDS Coordinator confirmed that the resident was incorrectly coded as receiving anticoagulant medication, acknowledging it was an error. The resident, admitted with diagnoses including Type 2 Diabetes Mellitus, Chronic Pulmonary Edema, and Heart Failure, was not on anticoagulant medication during the specified observation period.
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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