Trend Health & Rehab Of Meridian Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Meridian, Mississippi.
- Location
- 517 33rd Street, Meridian, Mississippi 39305
- CMS Provider Number
- 255348
- Inspections on file
- 16
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Trend Health & Rehab Of Meridian Llc during CMS and state inspections, most recent first.
A resident with dementia and severely impaired cognition had active PRN orders for Lorazepam and Diazepam that were entered without required 14-day stop dates, contrary to facility policy and federal requirements. Policy required all PRN psychotropic medications to be limited to a 14-day duration unless a physician documented clinical rationale and specified a longer duration. Review of records and a pharmacy consultant report showed the PRN psychotropic orders remained active beyond 14 days without documented physician justification or renewal. The DON, Administrator, and pharmacy consultant each confirmed that these PRN psychotropic orders should have been time-limited and either discontinued or renewed with appropriate documentation.
A resident with dementia and severely impaired cognition experienced multiple falls over an extended period, but the facility failed to revise and date the comprehensive care plan to reflect new or individualized fall-prevention interventions after each event. Policy required ongoing assessment and timely care plan updates when conditions changed, including after falls. Review of the care plan showed multiple fall dates listed under a fall-related focus, but the associated interventions were not dated, and there was no clear evidence of additional or revised interventions following subsequent falls. In interviews, an LPN/MDS coordinator and the DON confirmed that care plans should be individualized, updated after falls, and include dated interventions, and acknowledged that this resident’s care plan did not meet those expectations.
A resident with COPD and heart failure did not receive Albuterol inhaler as ordered for shortness of breath and wheezing after an LPN, uncomfortable with the medication sequence, withheld the medication without clinical justification or provider consultation. The DON advised withholding the medication if the nurse was uncomfortable, and no documentation or assessment was completed to support this action.
A resident with depression, anxiety, and dementia experienced the recent loss of her son and repeatedly requested support for her grief. Despite these requests, staff only placed her on bereavement watch, which involved monitoring behaviors, and did not arrange timely behavioral health services or counseling. The psychiatric provider had not seen the resident since before her loss, and there was no specific policy in place to address grieving residents beyond basic monitoring.
A bottle of TUMS and a bag of cough drops were found in a resident's bedside basket, accessible despite facility policy requiring medications to be locked and only accessible to authorized personnel. The DON confirmed the medications were present and stated that the resident, who is legally blind and has episodes of confusion, should not have medications at the bedside.
A resident reported that a CNA was rough during a transfer, causing pain. Another CNA witnessed the incident but did not report it. Both CNAs had received training on abuse prevention. The resident, who is cognitively intact and has paraplegia, later reported the incident, leading to an investigation and suspension of the CNAs.
A resident reported that a CNA was rough during a transfer, causing pain. Another CNA witnessed the incident but did not report it, despite knowing the requirement to do so within two hours. Both CNAs had received training on the facility's abuse policy.
The facility failed to prevent the spread of infection by not using a barrier during eye drop administration and inadequately cleaning a glucometer between residents. An LPN placed an eye drop bottle directly on a bedside table and did not follow the proper cleaning protocol for a glucometer, which was then used on another resident. These actions were confirmed by the LPN and the DON.
Failure to Limit PRN Psychotropic Medications to Required 14-Day Duration
Penalty
Summary
The facility failed to ensure PRN psychotropic medications were limited to a 14-day duration or renewed with documented physician rationale for one resident. Facility policy dated 4/28/25 required that PRN psychotropic medications, excluding antipsychotics, be limited to no more than 14 days, and that PRN antipsychotics be limited to 14 days with no exceptions. The resident, admitted on 8/27/2024, had dementia and a BIMS score of 00 on a quarterly MDS with an ARD of 2/16/2026, indicating severely impaired cognition. Record review showed active physician orders as of 3/1/26 for Diazepam 2 mg PO every 12 hours PRN for muscle spasms (ordered 12/30/2025) and Lorazepam 1 mg equivalent (0.5 mL of 2 mg/mL oral concentrate) PO every 6 hours PRN for agitation (ordered 12/29/2025), with no stop dates indicated. A pharmaceutical consultant report dated 1/26/26 identified the resident as prescribed psychoactive medications and specifically noted that PRN psychotropic orders are limited to a 14-day supply. The DON confirmed that Lorazepam and Diazepam are psychotropic medications and that PRN psychotropics must be limited to 14 days unless the physician documents a clinical rationale and specifies a longer duration, acknowledging that the staff member who entered the orders did not include end dates and that this was inconsistent with regulatory requirements and facility expectations. The Administrator also confirmed that the PRN psychotropic orders lacked the required 14-day stop dates. The pharmacy consultant further confirmed that the PRN Lorazepam and Diazepam orders should have been limited to 14 days or discontinued absent a new physician order or documented justification, and stated that the facility is responsible for ensuring PRN psychotropic medications are monitored and discontinued or renewed within the required timeframe.
Failure to Revise and Date Fall-Related Care Plan Interventions After Multiple Falls
Penalty
Summary
The deficiency involves the facility’s failure to revise and properly date a comprehensive care plan after multiple falls experienced by a resident. The facility’s policy, dated 10/2016, requires an individualized, person-centered comprehensive care plan with measurable objectives and timetables, and specifies that assessments are ongoing and care plans are revised as resident conditions change. For one resident admitted in late August 2024 with dementia and a BIMS score of 00 indicating severely impaired cognition, the care plan contained a fall-related focus listing multiple fall dates from November 2024 through February 2026. However, the interventions on the care plan were not dated to show when they were implemented or revised, and there was no documentation that the care plan had been updated with new or individualized interventions following each fall. Record review of fall investigations showed that the resident sustained falls on several specific dates in December 2025 and February 2026. During interviews, the LPN/MDS Coordinator stated that care plans are required to be individualized and updated when there is a change in condition, including after falls, and that interventions should be clearly documented and dated to reflect when they were implemented. She confirmed that the resident’s fall interventions were not dated and that the care plan did not reflect additional or updated interventions after subsequent falls, making it difficult to determine when interventions were implemented or whether the care plan had been revised. The DON similarly confirmed that care plans are expected to be individualized and updated after falls, with dated interventions, and acknowledged that the resident’s care plan did not show additional or revised interventions with appropriate dates following the multiple fall incidents, which was inconsistent with facility expectations and policy.
Failure to Administer Ordered Albuterol Inhaler for Resident with Respiratory Needs
Penalty
Summary
The facility failed to ensure that a resident received respiratory treatment and care in accordance with professional standards and physician orders. Specifically, the resident, who had diagnoses including Chronic Diastolic Congestive Heart Failure, Essential Hypertension, and COPD, had active orders for Budesonide Inhalation Suspension twice daily and Albuterol Sulfate HFA every four hours as needed for shortness of breath and wheezing. Despite these orders, the resident did not receive her Albuterol inhaler as prescribed on two consecutive days. The resident reported this omission and stated she had been receiving her inhaled medications in a specific sequence for years, with Albuterol administered prior to Budesonide, which she found effective for her symptoms. The failure occurred when the assigned LPN was uncomfortable administering the medications in the requested sequence and, after consulting with the on-call nurse and the DON, was advised to withhold the Albuterol if uncomfortable. No clinical assessment, provider consultation, or documentation of clinical justification for withholding the medication was completed. The DON acknowledged that the medication was not administered as ordered and that the provider should have been contacted for clarification if there was uncertainty. The nurse practitioner later confirmed that the orders were to be followed as written.
Failure to Provide Necessary Behavioral Health Services Following Resident Bereavement
Penalty
Summary
A resident with a history of depression, anxiety disorder, dementia, and bipolar disorder experienced the recent loss of her son and repeatedly expressed a need to talk with someone about her grief. Despite informing multiple staff members of her need for support and specifically requesting to speak with Social Services or a therapist, the resident did not receive timely behavioral health care or counseling. Staff interviews confirmed that the resident consistently voiced her need for support, but interventions were limited to attempts at distraction by a CNA and placement on 'bereavement watch,' which only entailed monitoring for behavioral changes. The Social Service Director and LPN confirmed that there was no specific policy or procedure in place to support grieving residents beyond charting behaviors, and the contracted psychiatric provider had not seen the resident since before her loss. The DON acknowledged a lapse in the process regarding staff follow-up, and the psychiatric provider confirmed he had not seen the resident due to time constraints. Documentation showed the resident continued to display symptoms of anxiety, confusion, depression, and social isolation, but no additional behavioral health services were provided in response to her bereavement.
Medications Improperly Stored at Bedside
Penalty
Summary
Surveyors observed that a bottle of TUMS and a bag of cough drops were stored in a resident's bedside basket, making medications accessible to the resident. The facility's policy requires that only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications have access to medications, and that medication rooms, carts, and supplies are to be locked when not attended by authorized personnel. The Director of Nursing (DON) confirmed the presence of these medications at the bedside and stated that medications are not to be stored at the bedside due to the risk of residents self-administering them. The resident involved was legally blind, had a history of wandering, and experienced episodes of confusion, which the DON stated made her unable to safely self-administer medications. Despite this, the resident's Minimum Data Set (MDS) assessment indicated a BIMS score of 15, showing cognitive intactness. The facility's failure to ensure medications were securely stored and not accessible to the resident constituted a violation of their own policy and regulatory requirements.
Failure to Prevent Abuse During Resident Transfer
Penalty
Summary
The facility failed to prevent the abuse of a resident, identified as Resident #25, who reported that a Certified Nurse Aide (CNA) was rough with him during a transfer from his wheelchair to his bed. Resident #25 stated that CNA #1 jerked the leg straps of the lift sling hard, causing him pain, and did not respond when he expressed that it hurt. This incident was witnessed by CNA #2, who confirmed that CNA #1 handled the resident roughly and did not report the incident despite knowing she should have. The resident had not initially reported the incident to anyone but later disclosed it to the Administrator and Social Worker, prompting an investigation and the suspension of both CNAs involved pending the outcome of the investigation. The facility's records show that both CNAs had received in-service training on the facility's abuse policy and the importance of preventing and reporting abuse. Resident #25, who has a medical diagnosis of paraplegia and a BIMS score indicating cognitive intactness, was admitted to the facility in January 2022. The Administrator confirmed that the incident was reported to the State Agency and that the investigation was ongoing. CNA #1 denied the resident's allegations during her interview, while CNA #2 admitted to witnessing the rough handling but did not report it due to the resident's request.
Failure to Report Abuse Timely
Penalty
Summary
The facility failed to report abuse in a timely manner for one of the residents reviewed for abuse. The facility's policy requires all employees to immediately report any incidents or suspected incidents of resident abuse. On 4/10/24, Resident #25 reported that on the previous day, CNA #1 was rough with him during a transfer, causing him pain. Despite Resident #25's complaints, CNA #1 continued to handle him roughly. CNA #2, who was present during the incident, confirmed the rough handling but did not report it because the resident did not want her to, even though she knew she was supposed to report it within two hours. The Administrator confirmed that CNA #2 admitted to witnessing the rough handling but did not consider it abuse and therefore did not report it. Both CNA #1 and CNA #2 had received in-service training on the facility's abuse policy, types of abuse, and the requirement to report abuse immediately. Resident #25, who has a medical diagnosis of paraplegia and a BIMS score indicating he is cognitively intact, reported the incident to the Administrator and Social Worker. The Administrator confirmed that the abuse should have been reported within two hours and that he expected all staff to comply with this policy. The failure to report the abuse in a timely manner constitutes a deficiency in the facility's adherence to its own policies and procedures.
Infection Control Deficiency
Penalty
Summary
The facility failed to prevent the possibility of the spread of infection as evidenced by improper handling of eye drops and inadequate cleaning of a glucometer. Specifically, an LPN administered eye drops to a resident without using a barrier, placing the eye drop bottle directly on the resident's bedside table. Additionally, the same LPN did not follow the proper cleaning protocol for a glucometer, wiping it for only 30 seconds instead of the required 2 minutes, and then used the inadequately cleaned glucometer on another resident. These actions were observed during direct care and confirmed by the LPN and the Director of Nurses (DON). The residents involved had medical conditions that required specific care. Resident #12 and Resident #24 had Type 2 Diabetes Mellitus and required regular blood sugar checks, while Resident #13 had a lack of coordination and required frequent eye drops for dry eyes. The LPN's failure to use a barrier for the eye drops and to properly clean the glucometer between uses could have led to the spread of infection or cross-contamination, as confirmed by both the LPN and the DON during interviews.
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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