The Oaks Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Meridian, Mississippi.
- Location
- 3716 Highway 39 North, Meridian, Mississippi 39301
- CMS Provider Number
- 255261
- Inspections on file
- 23
- Latest survey
- November 19, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at The Oaks Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident was found with long, jagged toenails and reported not receiving assistance with nail care, despite requesting help. This repeated deficiency occurred due to staff overlooking grooming during ADL care and a lack of effective follow-through on the facility's QAPI plan, as confirmed by interviews with the Administrator and DON.
A resident with severe cognitive impairment and physical limitations did not receive needed assistance with grooming and personal hygiene, including facial hair removal and toenail trimming. Despite expressing a desire for help and being unable to perform these tasks independently, staff did not provide the required care, contrary to facility policy and staff responsibilities.
A blind, cognitively intact resident was unable to access or verify the function of the call light system, as it was consistently placed out of reach and not adapted for her vision impairment. Staff interviews and observations confirmed the call light was attached to the wall at the foot of the bed, leaving the resident to yell for assistance. The DON acknowledged the need for more accessible devices for residents with vision loss.
A resident with severely impaired cognition and a stage 3 pressure ulcer did not receive required weekly skin integrity assessments, as documentation was only completed once despite facility policy and a QAPI intervention. The DON and NHA confirmed that the facility failed to consistently perform and document these evaluations for a high-risk individual.
A CNA failed to provide complete perineal care to a resident with severe contractures and cognitive impairment, cleaning only the anal area and omitting care to the vaginal area after a bowel movement. The omission was confirmed by interviews with the CNA, RN, and DON, and was not in accordance with facility policy or professional standards.
Surveyors found a box of moldy oranges with gnats and an unsealed bag of food thickener exposed to air during a kitchen tour. Dietary staff and management confirmed that these items were not properly stored or disposed of, in violation of facility policy, and acknowledged the potential for foodborne illness due to these lapses.
Staff failed to follow hand hygiene protocols during wound and perineal care for a resident with multiple diagnoses and severe cognitive impairment. A nurse did not perform hand hygiene at each step of wound care, and a CNA did not sanitize hands before donning gloves for perineal care. Facility leadership confirmed these actions did not comply with infection prevention policies and placed the resident at risk for infection.
Two residents with cognitive impairments were subjected to physical and verbal abuse by a CNA, with incidents witnessed by other staff who failed to report the abuse immediately due to fear of retaliation. The delay in reporting resulted in the CNA continuing to work with vulnerable residents for several days, contrary to facility policy and placing residents at risk.
Two residents, both with cognitive impairments, experienced physical and verbal abuse by a CNA, which was witnessed by other CNAs who failed to intervene or report the incidents immediately due to fear of retaliation, despite being trained on the facility's abuse policy and reporting requirements.
Staff failed to promptly report and investigate multiple incidents of physical and verbal abuse involving two residents, with delays attributed to fear of retaliation and oversight. Required notifications to the Administrator and State Agency were not made within mandated timeframes, resulting in Immediate Jeopardy and Substandard Quality of Care.
A resident with Parkinson's Disease and dementia, who exhibited aggressive behaviors, did not receive care in accordance with their individualized care plan. During an episode of agitation, staff failed to follow prescribed interventions such as stepping away and returning later, resulting in inappropriate physical handling and a nosebleed. Facility staff and leadership confirmed the care plan was not followed.
Due to a staffing shortage, only one CNA was present during an overnight shift, leaving a resident with an overactive bladder and urinary incontinence without timely care and resulting in the resident remaining soiled all night. Attempts by LPNs to contact the DON and scheduler for assistance were unsuccessful, and no additional staff could be secured.
The facility's assessment failed to specify staffing needs by shift, lacked a recruitment and retention plan, and did not include contingency planning for non-emergency situations. As a result, a resident with an overactive bladder was left in urine overnight when only one CNA was on duty, highlighting insufficient staff coverage and planning.
Daily nurse staffing information was not posted in a visible and accessible location for two consecutive days. Multiple staff, including LPNs and the DON, confirmed the absence of required postings, and no alternative location was identified. This failure limited access to staffing information for residents, families, and the public.
Repeated Deficiency in Resident Nail Care Due to Ineffective QAPI Implementation
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) plan, as evidenced by a repeated deficiency related to resident grooming. Specifically, the facility was cited for not ensuring that a resident's nails were clipped, an issue that was previously identified in a prior annual recertification survey. During the most recent survey, a resident was observed with long and jagged toenails and expressed that she had not received assistance with nail care, despite requesting help. This observation was supported by staff and resident interviews, as well as a review of facility policies and prior statements of deficiencies. Interviews with facility leadership revealed a lack of clarity regarding the reasons for non-adherence to the previous plan of correction for Activities of Daily Living (ADL) care. The Administrator was unable to specify why the plan was not being followed, while the DON suggested that staff may be overlooking nail care during routine grooming. The facility's policy on QAPI, which outlines the establishment of performance indicators and systematic actions to improve performance, was reviewed but not effectively implemented to prevent recurrence of the deficiency.
Failure to Provide Necessary ADL Assistance for Grooming and Hygiene
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and physical limitations did not receive necessary assistance with activities of daily living (ADLs), specifically grooming and personal hygiene. Observations revealed the resident had long, visible facial hair on her chin and upper lip, as well as long, jagged toenails. The resident expressed a desire for assistance with hair removal and toenail trimming, stating that staff had not provided this help and that she was unable to perform these tasks herself due to her health challenges. Interviews with staff confirmed that grooming tasks, including facial hair removal, are the responsibility of CNAs during daily ADL care, and toenail trimming is assigned to LPNs. Staff members were not aware of the resident refusing care, and both the DON and LPN confirmed that these services should have been provided. The facility's policy requires staff to encourage resident participation in ADLs and provide assistance as necessary, but this was not followed for the resident in question.
Failure to Individualize Call Light System for Blind Resident
Penalty
Summary
The facility failed to reasonably accommodate the needs of a blind resident by not individualizing the call light system to ensure accessibility. The resident, who is legally blind and cognitively intact, reported being unable to see or reach the call light in her private room. She stated that even when the call light was within reach, she could not determine if it was functioning, leading her to feel uncertain and vulnerable when needing assistance. Multiple interviews with staff, including a CNA and an LPN, confirmed that the call light was attached to the wall at the foot of the bed and was not accessible to the resident. Staff acknowledged that the call light was not placed within the resident's reach during the night and that this was a consistent issue. Observations conducted by surveyors corroborated the resident's statements, as the call light was repeatedly found out of reach. The Director of Nursing also recognized the need for a more accessible device for residents with vision impairments. The facility's policy on resident rights was reviewed, which mandates that residents are not deprived of their rights, but the policy was not followed in this case. The resident's medical record confirmed her legal blindness and anxiety disorder, further emphasizing the necessity for individualized accommodations that were not provided.
Failure to Document Weekly Skin Integrity Assessments for High-Risk Resident
Penalty
Summary
The facility failed to ensure ongoing assessment and documentation of skin integrity for a resident at high risk for skin breakdown. According to facility policy, a licensed nurse is required to complete and document a total body skin evaluation weekly for each resident. However, for one resident with a history of contractures and a stage 3 pressure ulcer, the Weekly Skin Integrity Review was only documented once, with no further weekly assessments recorded as required. This lapse occurred even after a QAPI intervention was initiated, and the lack of documentation persisted. Interviews with the DON confirmed that the facility was aware of the missed reviews but did not effectively implement the QAPI plan, resulting in continued failure to document weekly skin checks for the high-risk resident. The NHA also acknowledged that the facility did not follow through with its internal corrective strategies. The resident in question had severely impaired cognition and required ongoing wound care for a stage 3 pressure ulcer, as indicated by physician orders and clinical records.
Incomplete Perineal Care Provided to Resident with Contractures
Penalty
Summary
A deficiency was identified when a Certified Nursing Assistant (CNA) failed to provide complete perineal care to a resident with a history of muscle contractures and severely impaired cognition. During an observed wound care session, the CNA cleaned only the anal area after a bowel movement, neglecting to clean the front vaginal area as required by facility policy and professional standards. The CNA did not perform hand hygiene upon re-entering the room before donning gloves and did not follow the protocol of cleaning from front to back to avoid contamination. Interviews with the CNA, the Registered Nurse (RN) assisting with wound care, and the Director of Nursing (DON) confirmed that the perineal care was incomplete and not performed according to policy. The staff acknowledged that the resident, who was contracted and difficult to clean, did not receive care to the vaginal area, which was required. The facility's policy and staff statements indicated that the omission placed the resident at risk for complications.
Improper Food Storage and Disposal in Dietary Services
Penalty
Summary
During a kitchen tour, surveyors observed a ten-pound box of Sunkist oranges under a prep table that was three-fourths full and contained three oranges with black and white mold. Gnats were seen flying out of the box when it was opened. Additionally, an unsealed bag of food thickener with a hole in it was found exposed to the air. Both items were not properly stored or disposed of according to the facility's food preparation policy, which requires staff to avoid contamination by harmful agents. Interviews with dietary staff and management confirmed that the oranges had been received earlier in the month and should have been discarded, and that the thickener should have been sealed and dated. The Dietary Manager acknowledged responsibility for checking behind the cook, and the cook admitted to not paying attention to proper storage procedures. The Director of Food Services and the Nursing Home Administrator both confirmed that these lapses could lead to foodborne illness and that staff are expected to maintain proper food storage and dating compliance.
Failure to Follow Hand Hygiene Protocols During Wound and Perineal Care
Penalty
Summary
The facility failed to provide perineal and wound care in a manner that prevents the spread of infection for two of five observed care events involving a resident with multiple diagnoses, including contracture of muscle and essential hypertension, and severely impaired cognition. During wound care, the registered nurse did not perform hand hygiene after initiating the procedure, and the certified nursing assistant did not sanitize hands before applying clean gloves after returning to the room to assist with perineal care. Both staff members acknowledged their lapses in hand hygiene, with the CNA admitting to forgetting to wash hands and the RN confirming failure to perform hand hygiene at each step of the wound care process, including after cleansing, drying, applying collagen, and dressing the wound. Interviews with the infection preventionist and the director of nursing confirmed that both staff members did not follow facility policies regarding hand hygiene and glove changes during wound and perineal care. The facility's policies require hand hygiene before and after care, as well as glove changes and hand sanitization at each phase of wound care. The staff's failure to adhere to these protocols placed the resident at risk for wound and urinary tract infections, as confirmed by the facility's leadership during interviews.
Failure to Protect Residents from Abuse Due to Delayed Reporting and Inaction
Penalty
Summary
The facility failed to protect residents from physical and verbal abuse, as evidenced by two separate incidents involving a certified nurse aide (CNA). In one incident, a CNA was witnessed physically abusing a resident with Parkinson's Disease and Dementia, who had moderately impaired cognition. The CNA grabbed the resident's nose and twisted it, causing bleeding, and made a derogatory comment. In another incident, the same CNA verbally threatened a different resident, who had severe cognitive impairment and was dependent on staff for toileting hygiene, by stating she would beat the resident if she soiled the bed again. Both incidents were witnessed by other CNAs. Despite these events, the staff members who witnessed the abuse did not immediately report the incidents to the nurse, DON, or Administrator. The witnesses cited fear of retaliation and concerns about job security as reasons for not reporting. As a result, the Administrator was not informed of the allegations until ten days after the initial incident, leaving the residents and others vulnerable during that period. Interviews with additional staff revealed that the CNA in question was known to speak to residents in an aggressive or angry manner, but this behavior was dismissed by some staff as part of her personality and not reported to management. The facility's own policy required immediate reporting and action in cases of abuse, but this was not followed. The delay in reporting and lack of immediate protective action allowed the CNA to continue working with vulnerable residents, placing them at risk for further harm. The deficiency was identified through interviews, record reviews, and the facility's internal investigation, which substantiated the abuse allegations based on staff witness statements.
Removal Plan
- Quality Assurance (QAPI) Committee met to review, develop, and implement the facility policy on abuse and neglect with an emphasis on reporting abuse and neglect and to determine the root cause. The root cause was determined to be that employees were afraid of retaliation from other employees. Attendees included the Executive Director, Minimum Data Service nurse, Medical Records, Regional Director of Clinical Services, Assistant Director of Nursing, Medical Director, Social Services, Staff Development/Infection Preventionist nurse, Activities Director, Human Resources, Housekeeping, Dietary Manager, Therapy director, Unit Managers, and the Admission Coordinator. No changes were made to the policy and procedure. The areas discussed were the re-education of staff members on the abuse and neglect policy with an emphasis on reporting requirements and that failure to do so is a crime.
- Body audits were completed on Resident #1 and Resident #2 by the Staff Development nurse and a licensed nurse. No signs of physical abuse were identified.
- Interviews were conducted by Social Services Director with alert and oriented residents on side 2. No residents voiced complaints of abuse.
- The physician and the Resident Representatives of Resident #1 and Resident #2 were notified.
- Education was started by the Staff Development Nurse.
- Quality Assurance Performance Improvement Committee met to review the physical and verbal abuse.
- Social Services completed a psychosocial follow up with Resident #1 and Resident #2.
- 100% body audits were performed on all facility residents by the unit manager RN and the Minimum Data Set nurses to ensure that residents did not have physical signs of abuse. No residents were identified.
- The Executive Director was educated on the abuse policy by the Regional Director of Clinical Services and timely reporting of abuse within 2 hours to the state agency, attorney general and the abuse and neglect policy.
- The Social Services Director and the Admissions Coordinator interviewed all alert and oriented residents (census) using the Risk Management Quality Improvement Questionnaire to determine if any residents had been abused or witnessed abuse. There were no residents that voiced any complaints of abuse.
- The Staff Development nurse started education with licensed nurses, CNA's and non-direct care staff on the abuse and neglect policy and procedure with an emphasis on reporting requirements and 100% has been completed.
- All facility staff members were interviewed by the Executive Director, Human Resources, and Assistant Director of Nursing by phone to ask if they ever witnessed any employee abuse a resident and explained the process of what to do if they ever witness abuse or neglect, with an emphasis on reporting requirements and that failure to do so is a crime.
- CNA #2 received one on one education on the abuse policy and the reporting requirements with an emphasis placed on the fact of not reporting being a crime.
- New hires will be educated during orientation.
Failure to Implement Abuse Policy and Immediate Reporting
Penalty
Summary
The facility failed to implement its abuse policy, resulting in two incidents of abuse involving two residents. In the first incident, a resident with Parkinson's Disease and Dementia, who had a moderately impaired cognitive status, was physically abused by a CNA during care. The CNA responded to the resident's combative behavior by grabbing and twisting the resident's nose, causing it to bleed, and made a derogatory comment. This act was witnessed by another CNA, who did not immediately report the incident or intervene effectively, despite being aware of the facility's abuse policy and having received training on the obligation to report abuse. In the second incident, another resident with severe cognitive impairment and dependent on staff for toileting hygiene was verbally abused by the same CNA. The CNA threatened the resident with physical harm if the resident soiled the bed again. This was overheard by a different CNA, who confronted the abusive CNA but also failed to report the incident at the time. Both witnessing CNAs later admitted they did not report the abuse immediately due to fear of retaliation from other staff members, even though they were aware of the reporting requirements outlined in the facility's policy. The facility's policy required all employees to report any witnessed or known abuse within two hours to the Administrator and other officials as per state law. However, the incidents were not reported until anonymous letters were received by the Administrator, leading to a delayed response. The failure of staff to intervene and promptly report the abuse placed the affected residents and others at risk for further abuse and constituted a violation of residents' rights to be free from abuse.
Removal Plan
- Quality Assurance (QAPI) Committee reviewed, developed, and implemented the facility policy on abuse and neglect with an emphasis on reporting abuse and neglect and to determine the root cause.
- Body audits were completed on Resident #1 and Resident #2 by the Staff Development nurse and a licensed nurse.
- Interviews were conducted by Social Services Director with alert and oriented residents on side 2.
- The physician and the Resident Representatives of Resident #1 and Resident #2 were notified.
- Education was started by the Staff Development Nurse.
- Quality Assurance Performance Improvement Committee reviewed the physical and verbal abuse.
- Social Services completed a psychosocial follow up with Resident #1 and Resident #2.
- 100% body audits were performed on all facility residents by the unit manager RN and the Minimum Data Set nurses to ensure that residents did not have physical signs of abuse.
- The Executive Director was educated on the abuse policy by the Regional Director of Clinical Services and timely reporting of abuse to the state agency, attorney general and the abuse and neglect policy.
- The Social Services Director and the Admissions Coordinator interviewed all alert and oriented residents using the Risk Management Quality Improvement Questionnaire to determine if any residents had been abused or witnessed abuse.
- The Staff Development nurse started education with licensed nurses, CNAs and non-direct care staff on the abuse and neglect policy and procedure with an emphasis on reporting requirements.
- All facility staff members were interviewed by the Executive Director, Human Resources, and Assistant Director of Nursing by phone to ask if they ever witnessed any employee abuse a resident and explained the process of what to do if they ever witness abuse or neglect, with an emphasis on reporting requirements.
- CNA #2 received one on one education on the abuse policy and the reporting requirements with an emphasis placed on the fact of not reporting being a crime.
- New hires will be educated during orientation.
Failure to Timely Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to report suspected abuse within the required two-hour timeframe and did not submit a completed investigation for an allegation of abuse within five working days, as required by regulation. Two residents experienced abuse by a CNA, with one incident involving physical abuse resulting in a nosebleed and verbal abuse, and another incident involving verbal threats. Both incidents were witnessed by other CNAs, but neither was reported immediately due to fear of retaliation from staff. The abuse was only reported ten days after the initial incident, when anonymous letters were left for the Administrator. The facility's policy required any employee who witnesses or has knowledge of abuse, neglect, exploitation, or mistreatment to report the information within two hours to the Administrator and other officials in accordance with state law. Despite this, the CNAs who witnessed the abuse did not report it promptly, leaving residents at risk for continued abuse. The Administrator became aware of the incidents only after receiving anonymous letters, at which point the accused CNA was suspended and subsequently terminated. Additionally, the facility failed to submit a final investigation report to the State Agency within five working days for a separate allegation of verbal abuse involving another resident. The Administrator and DON acknowledged that the final report was not sent due to the DON's illness and oversight, despite being aware of the requirement. This failure to report and investigate in a timely manner was determined to be Immediate Jeopardy and Substandard Quality of Care.
Removal Plan
- Quality Assurance (QAPI) Committee met to review, develop, and implement the facility policy on abuse and neglect with an emphasis on reporting abuse and neglect and to determine the root cause. The root cause was determined to be that employees were afraid of retaliation from other employees. Attendees included the Executive Director, MDS nurse, Medical Records, Regional Director of Clinical Services, Assistant Director of Nursing, Medical Director, Social Services, Staff Development/Infection Preventionist nurse, Activities Director, Human Resources, Housekeeping, Dietary Manager, Therapy director, Unit Managers, and the Admission Coordinator. No changes were made to the policy and procedure. The areas discussed were the re-education of staff members on the abuse and neglect policy with an emphasis on reporting requirements and that failure to do so is a crime.
- Body audits were completed on Resident #1 and Resident #2 by the Staff Development nurse and a licensed nurse. No signs of physical abuse were identified.
- Interviews were conducted by Social Services Director with alert and oriented residents on side 2. No residents voiced complaints of abuse.
- The physician and the Resident Representatives of Resident #1 and Resident #2 were notified.
- Education was started by the Staff Development Nurse.
- Quality Assurance Performance Improvement Committee met to review the physical and verbal abuse.
- Social Services completed a psychosocial follow up with Resident #1 and Resident #2.
- 100% body audits were performed on all facility residents by the unit manager RN and the Minimum Data Set nurses to ensure that residents did not have physical signs of abuse. No residents were identified.
- The Executive Director was educated on the abuse policy by the Regional Director of Clinical Services and timely reporting of abuse within 2 hours to the state agency, attorney general, and the abuse and neglect policy.
- The Social Services Director and the Admissions Coordinator interviewed all alert and oriented residents (census) using the Risk Management Quality Improvement Questionnaire to determine if any residents had been abused or witnessed abuse. There were no residents that voiced any complaints of abuse.
- The Staff Development nurse started education with licensed nurses, CNAs, and non-direct care staff on the abuse and neglect policy and procedure with an emphasis on reporting requirements and 100% was completed.
- All facility staff members were interviewed by the Executive Director, Human Resources, and Assistant Director of Nursing by phone to ask if they ever witnessed any employee abuse a resident and explained the process of what to do if they ever witness abuse or neglect, with an emphasis on reporting requirements and that failure to do so is a crime.
- CNA #2 received one on one education on the abuse policy and the reporting requirements with an emphasis placed on the fact of not reporting being a crime.
- New hires will be educated during orientation.
Failure to Implement Comprehensive Care Plan Interventions for Resident with Behavioral Needs
Penalty
Summary
The facility failed to implement comprehensive care plan interventions for a resident with diagnoses including Parkinson's Disease and dementia, who exhibited behaviors such as occasional physical and verbal aggression. The resident's care plan, revised to address these behaviors, included specific interventions such as intervening before agitation escalates, guiding the resident away from distress, engaging calmly in conversation, and, if aggression occurred, staff were to walk away and return later. Despite these documented interventions, staff did not follow the care plan during an incident where the resident became agitated and physically aggressive during incontinence care. During the incident, a CNA held the resident's hands and attempted to reassure her, but the resident pulled away and grabbed another CNA by the hair. In response, the second CNA grabbed the resident's nose and twisted it, causing a nosebleed, and made an inappropriate comment. Interviews with staff and facility leadership confirmed that the care plan was not followed, as staff did not step away and allow the resident time to calm down before reattempting care, contrary to the established interventions for managing the resident's behaviors.
Insufficient Staffing Leads to Resident Left Soiled Overnight
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, resulting in a resident being left soiled throughout the night. On the overnight shift in question, only one CNA was present in the facility, despite the staffing grid indicating that more were needed. Three CNAs failed to call in for their shift, and attempts by the LPN on duty to contact the DON and the scheduler for assistance were unsuccessful. The LPN was given a list of potential replacements, but none were available, and no further support was provided by facility leadership. As a result of the staffing shortage, a resident with a diagnosis of overactive bladder and documented as always incontinent of urine was unable to receive timely incontinence care. The resident reported being left in urine for the entire night, causing discomfort. The resident was cognitively intact and able to clearly describe the incident, stating that the lack of staff directly led to her needs not being met.
Facility Assessment Lacks Required Staffing Details and Contingency Planning
Penalty
Summary
The facility failed to include all required elements in its Facility Assessment, specifically omitting detailed staffing needs by shift, a plan for recruitment and retention of staff, and contingency planning for situations that do not require activation of the emergency operations plan. The Facility Assessment only identified total staffing numbers needed over a 24-hour period and did not specify requirements for each eight-hour shift or account for changes in the resident population. During an interview, the Administrator acknowledged a lack of awareness regarding the federal requirement to address staffing by shift and confirmed the assessment's deficiencies. Additionally, a resident interview revealed that on one overnight shift, only one CNA was present, resulting in the resident being left in urine throughout the night due to insufficient staff coverage. The resident, who has an overactive bladder and is always incontinent of urine, expressed discomfort and noted the absence of contingency plans for staffing shortages. Review of facility records confirmed the resident's medical condition and the staffing grid for the shift in question, substantiating the reported deficiency.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that daily nurse staffing information was posted in a visible and accessible location for two out of three survey days. Observations on multiple occasions revealed that the required staffing postings were not present in the designated area near the copier room in a glass case, nor was an alternative posting location identified. Interviews with LPNs and the Director of Nursing confirmed that the staffing information was not posted as required, and a review of facility records showed that postings were missing for the specified days. The Administrator acknowledged that the postings were not present for the previous two days and attributed the lapse to an oversight, despite internal tracking of staffing. The absence of posted staffing information limited residents, family members, and the public from accessing required information and impeded transparency regarding facility staffing levels, as confirmed by staff interviews and record review.
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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