Woodlands Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Clinton, Mississippi.
- Location
- 102 Woodchase Park Drive, Clinton, Mississippi 39056
- CMS Provider Number
- 255148
- Inspections on file
- 27
- Latest survey
- April 29, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Woodlands Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
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 observed two medication administration errors, resulting in a medication error rate above 5%. One resident was not instructed to rinse their mouth after receiving a steroid inhaler, and another was nearly given an incorrect dose of Thiamine by an LPN, contrary to physician orders. The DON confirmed the importance of following proper medication administration procedures.
Staff failed to follow infection prevention and control protocols during care for three residents, including not performing hand hygiene between glove changes, not wearing gowns as required by Enhanced Barrier Precautions, and using contaminated gloves to handle supplies. These lapses occurred during wound care, perineal care, and PEG site care for residents with pressure ulcers and severe cognitive impairment.
A resident with a diagnosis of dementia, but who was cognitively intact, was not informed of their right to formulate an advance directive (AD) nor offered assistance in doing so. Review of the clinical record and confirmation by an LPN showed no documentation of this required process, and the Administrator acknowledged that no steps had been taken to address the lack of an AD after it was identified during a care plan conference.
A resident with a feeding tube and a history of hemiplegia and hemiparesis did not receive care in accordance with their care plan, which required Enhanced Barrier Precautions. During observed peri care, a CNA failed to wear a protective gown as specified in the care plan, despite having received EBP training. The RN confirmed that the care plan was not followed during this incident.
A resident with a history of syncope and coded as dependent for transfers was left unsafely supervised during a shower transfer when a CNA, unfamiliar with the resident, attempted to transfer the resident alone despite visible weakness and shaking. The CNA did not follow the care plan or seek help, and the DON confirmed that proper transfer protocols were not followed.
A resident with End Stage Renal Disease repeatedly arrived late to scheduled dialysis appointments due to transportation delays and unclear communication about chair times, resulting in multiple shortened dialysis sessions over the course of a month. Staff interviews and documentation confirmed ongoing issues with van availability and coordination with the dialysis clinic, leading to incomplete treatments for the resident.
A medication prescribed for a resident with acute and chronic respiratory failure was found unattended and unsecured on a bedside table, contrary to facility policy requiring all medications to be stored in locked compartments. The DON confirmed that staff should not leave medications in resident rooms and that the resident was not able to self-administer the inhaler.
A resident's medical record lacked documentation regarding the presence, refusal, or offer of assistance for an advance directive (AD). An LPN and the Administrator confirmed that no such information was available in the electronic health record, and the resident, who was cognitively intact and had no POA or AD, had lived in the facility for several years. No steps were taken to document the AD status after it was identified as missing during a care plan conference.
The QAPI Committee failed to prevent recurrence of a medication error rate above 5%, as evidenced by two medication errors out of 31 opportunities, including a resident not instructed to rinse after a steroid inhaler and another given an incorrect Thiamine dose. This repeated deficiency occurred despite previous citations and ongoing committee meetings.
A resident with severe cognitive impairment left an LTC facility unsupervised after a transportation aide allowed them to exit through the front door. The resident was later found across the street, unsupervised for approximately 13 minutes. The facility's failure to provide adequate supervision and implement its wanderer management policy led to this Immediate Jeopardy and Substandard Quality of Care incident.
A resident in a long-term care facility was physically and emotionally abused by a CNA, who handled the resident roughly, sprayed cold water on his face, and turned off the lights in the shower room while laughing. The incident was witnessed by an LPN who intervened, but the facility failed to act promptly, allowing the CNA to continue working for several days. The resident reported feeling sad and taken advantage of, and the facility's delay in addressing the abuse led to a determination of Immediate Jeopardy and Substandard Quality of Care.
A resident experienced physical and emotional abuse by a CNA, which was witnessed by an LPN. The incident involved rough handling during care, including spraying the resident with cold water and turning off the lights. Despite the LPN reporting the incident to the charge nurse and Administrator, the facility failed to report it to the State Agency within the required timeframe, increasing the risk of harm.
The facility failed to ensure a clean and homelike environment for three residents, resulting in strong urine odors and unsanitary conditions in their rooms. A resident's room had a strong urine odor due to a wet incontinence brief, while two residents in a shared room experienced similar issues with a urinal and spilled urine. Staff interviews confirmed the odors and the need for immediate cleaning, highlighting a failure to provide timely and adequate care for residents with various medical conditions.
Two residents in a facility did not receive care as outlined in their comprehensive care plans, leading to deficiencies. One resident was left in a saturated incontinence brief for over two hours, while another was found sitting on a soaked incontinence pad with a strong urine odor in the room. Both residents required assistance with personal hygiene and toileting, which was not adequately provided.
Two residents in an LTC facility did not receive timely incontinence care as required. One resident was found with a saturated brief, and the CNA admitted to not checking for over two hours. Another resident had a soaked incontinence pad, with care delayed for nearly three hours. Both residents required assistance due to their medical conditions, and staff confirmed the expectation of two-hourly rounds was not met.
A facility failed to maintain a mechanical lift in safe working condition, leading to a malfunction during a resident transfer. Staff attempted to resolve the issue by replacing batteries, but the lift only worked when the battery was manually squeezed into place. Interviews revealed a lack of communication and reporting of the malfunction, and the Maintenance Director had not received any work orders for the lift. The resident involved had a history of cerebrovascular disease, repeated falls, and malignant neoplasm of the bladder.
A resident admitted with severe hip pain did not receive timely pain management due to the facility's failure to notify the physician, as required by policy. Despite reporting pain at a level 9 out of 10, the resident did not receive pain medication until hours later, and the nurse did not inform the primary healthcare provider of the resident's condition.
A resident who had undergone hip replacement surgery reported severe pain upon admission to the facility, but did not receive pain medication until over five hours later. Despite having a prescription for Oxycodone-Acetaminophen, the nursing staff failed to administer the medication in a timely manner or notify the primary healthcare provider about the unrelieved pain. The facility's policies for pain management were not followed, resulting in a delay in addressing the resident's pain.
A facility failed to follow physician orders and dialysis aftercare communication for a resident with an AV shunt. Despite instructions to remove the pressure dressing within a specified timeframe, the resident returned from dialysis with the dressing still in place. Communication issues between the dialysis unit and facility staff contributed to this deficiency, as acknowledged by the DON.
A resident was discharged home with medications and home health services, but the MDS was incorrectly coded as a discharge to a short-term general hospital. The error was confirmed by the MDS Coordinator and DON, who acknowledged that the resident was discharged to live with her sister. The MDS was coded by an LPN, and the Administrator expected the MDS Coordinator to verify the coding accuracy.
A facility failed to conduct a PASRR Level II for a resident with Paranoid Schizophrenia who transitioned from short-term to long-term care. The resident was admitted for short-term therapy, but the necessary screening was not updated when their care status changed. Staff interviews revealed a lack of awareness about the requirement for a Level II PASRR referral.
A facility failed to maintain a medication error rate below 5%, resulting in an 8% error rate. An RN administered two different eye drops to a resident without waiting the required three to five minutes between applications, as per facility policy. The resident had orders for these drops following eye surgery. Despite attending an inservice on medication procedures, the RN only waited 20 seconds between administering the drops, leading to the error.
A CNA was observed carrying dirty linen against her clothes instead of using a leak-proof bag, contrary to the facility's infection control policy. The DON confirmed this action could lead to infections. Despite prior training, the CNA did not follow proper procedures.
The facility failed to update care plans for two residents, leading to deficiencies in their care. One resident's care plan lacked instructions for timely removal of a dialysis dressing, despite repeated communications from the dialysis unit. Another resident's care plan inaccurately indicated continuous tube feedings, although the order had changed to bolus feedings due to aspiration risk. These issues were not addressed until after the State Agency's entrance, revealing lapses in communication and documentation by nursing staff.
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.
Medication Error Rate Exceeds Regulatory Threshold Due to Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required by policy, resulting in a 6.45% error rate during the survey period. Two medication errors were observed among 31 opportunities. In the first instance, an LPN administered Symbicort Inhalation Aerosol to a resident with a diagnosis of Toxic Encephalopathy and a BIMS score indicating cognitive intactness, but did not instruct the resident to rinse their mouth after administration. Both the LPN and the DON confirmed that mouth rinsing is necessary after using an inhaled corticosteroid to prevent oral thrush, and the medication guide also specifies this step. In the second instance, another LPN prepared an incorrect dosage of Thiamine for a resident admitted with a humerus fracture. The LPN placed a 100 mg Thiamine tablet in the medication cup, despite the physician's order specifying a 50 mg dose. The LPN later confirmed the error upon reviewing the medication label and removed the incorrect tablet. The DON acknowledged that medications must be administered according to physician orders and that incorrect dosing could result in negative outcomes. These observed actions directly contributed to the facility's medication error rate exceeding the regulatory threshold.
Failure to Adhere to Infection Prevention and Control Protocols During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple staff not adhering to established protocols during resident care. During wound care for a resident with pressure ulcers, a registered nurse changed gloves five times without performing hand hygiene between glove changes, contrary to facility policy and training. The nurse admitted to being unaware of the requirement for hand hygiene between glove changes, and the Director of Nursing confirmed this was a breach of infection control standards. In another instance, a certified nursing assistant provided perineal care to a resident with severe cognitive impairment without donning a gown, as required by Enhanced Barrier Precautions (EBP), and failed to perform hand hygiene between glove changes. The CNA also used contaminated gloves to retrieve additional wipes from a package and did not place a barrier on the table or gather all necessary supplies before starting care. The CNA acknowledged these lapses and stated she had received training on both hand hygiene and EBP but failed to follow procedures during the care. Additionally, a licensed practical nurse performed PEG site care for a resident with severe cognitive impairment without wearing a protective gown, as required by EBP. The LPN admitted to not wearing the gown and recognized this as an infection control issue. The Director of Nursing confirmed that a gown should have been worn during this procedure. These incidents demonstrate a failure to follow the facility's infection prevention and control policies during direct resident care.
Failure to Inform Resident of Advance Directive Rights and Provide Assistance
Penalty
Summary
The facility failed to ensure that a resident was informed of their right to formulate an advance directive (AD) and was provided assistance to do so, as required by facility policy. A review of the resident's clinical record showed no documentation that the resident had been informed about ADs or offered help in creating one. This was confirmed by an LPN in Medical Records, who verified that the resident's entire chart had been scanned into the electronic health record and contained no such documentation. The facility's policy requires informing residents about their rights regarding ADs and providing written information and assistance if requested. Further review revealed that the resident had been admitted several years prior with a diagnosis of unspecified dementia but was currently cognitively intact, as indicated by a BIMS score of 15 on the most recent MDS assessment. During a recent care plan conference, it was identified that the resident had no Power of Attorney or AD in place, and the Administrator confirmed that no steps had been taken since that time to inform the resident of their rights or offer assistance in formulating an AD.
Failure to Implement Enhanced Barrier Precautions per Care Plan
Penalty
Summary
The facility failed to implement care plan interventions related to Enhanced Barrier Precautions (EBP) for one resident who required these precautions due to the presence of a feeding tube. The resident's care plan specifically included the use of EBP, such as wearing a protective gown during high-contact care activities like changing briefs. During an observation, a Certified Nursing Assistant (CNA) was seen providing perineal care to the resident without wearing a protective gown, contrary to the care plan's interventions. Upon interview, the CNA acknowledged that she did not wear a gown during peri care and admitted she forgot to do so, despite having received training on EBP. The Registered Nurse responsible for care planning confirmed that the CNA did not follow the comprehensive care plan and reiterated that staff are expected to adhere to the care plan interventions. The resident involved had a history of hemiplegia and hemiparesis following an unspecified cerebrovascular disease and had been admitted to the facility with these diagnoses.
Failure to Provide Adequate Supervision and Assistance During Resident Bathing
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to provide adequate supervision and assistance to a resident during bathing activities. The resident, who had a diagnosis of syncope and collapse and was coded as dependent for transfers on the Minimum Data Set (MDS), was observed being transferred from a rolling shower chair to a wheelchair by a single CNA. During the process, the resident was visibly weak, with shaking arms, and was required to stand twice without additional staff present. The CNA did not seek help despite the resident's instability and did not use the call light, citing concerns about response time and the presence of a surveyor. The CNA also admitted to making transfer decisions based on observation rather than the care plan or Kardex instructions. Interviews with the CNA and the Director of Nursing (DON) confirmed that the resident required more assistance than was provided and that proper protocols for transfer and supervision were not followed. The DON stated that both the care plan and the CNA Kardex contained clear guidance on transfer status, which was not adhered to during the incident. The failure to follow established procedures and to seek appropriate assistance placed the resident at risk for accidents or injury during the bathing process.
Failure to Provide Timely Transportation for Dialysis Resulting in Shortened Treatments
Penalty
Summary
The facility failed to ensure that a resident requiring hemodialysis was transported in a timely manner to receive the full duration of prescribed dialysis treatment. The resident, who had a diagnosis of End Stage Renal Disease and a physician's order for dialysis three times a week at a specified chair time, consistently arrived late to her appointments. Interviews and record reviews revealed that the resident's late arrivals occurred on multiple occasions over the previous month, resulting in shortened dialysis sessions. The dialysis Nurse Manager confirmed that the resident's average arrival time was significantly later than scheduled, and that the clinic had to adjust her chair time, which sometimes led to early termination of treatment due to the clinic's closing time. Contributing factors included unclear communication regarding chair time changes between the dialysis clinic and the facility, as well as transportation issues such as facility vans being out of service and reliance on an external transport provider with a history of tardiness. The resident expressed frustration with the repeated changes and late arrivals, noting the impact on her treatment schedule. Staff interviews confirmed awareness of the transportation challenges and the expectation that residents be transported on time, but documentation showed that the resident continued to experience delays and incomplete dialysis sessions.
Unsecured Medication Left Unattended in Resident Room
Penalty
Summary
A medication storage deficiency occurred when a medication prescribed to a resident was found unattended on the bedside table during an observation. The medication, Dulera Inhalation Aerosol, was labeled with the resident's identifying information and dosage instructions but was not secured in a medication cart or locked storage area as required by facility policy. No staff were present in the room at the time of the observation. The resident involved had a diagnosis of acute and chronic respiratory failure with hypoxia and was cognitively intact, as indicated by a BIMS score of 13. Facility policy required all drugs and biologicals to be stored in a safe, secure, and orderly manner. The DON confirmed that nurses were not supposed to leave medications in residents’ rooms and stated that the resident would not be able to self-administer the inhaler.
Failure to Document Advance Directive Status in Medical Record
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident by not documenting whether the resident had an advance directive (AD) in place, declined to complete one, or was offered assistance to formulate one. A review of the resident's clinical record showed no documentation regarding the AD status. During an interview and review of the electronic health record, an LPN confirmed that there was no information about the resident's AD in the system, and if it was not scanned into the new system, it was not present in the building. The Administrator also confirmed that the resident's AD information was not readily available in the medical record. The resident in question had been admitted to the facility several years prior with a diagnosis of unspecified dementia and was found to be cognitively intact based on a recent BIMS score. A care plan conference was held with the resident, during which it was identified that the resident had no Power of Attorney (POA) or AD in place. Despite this, the facility had not taken steps to ensure that the resident's AD status was documented in the medical record.
Repeat Medication Error Rate Deficiency Due to Ineffective QAPI Oversight
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to sustain corrective actions to prevent recurrence of previously cited deficiencies related to medication error rates. During an annual recertification survey, the facility was cited for failing to maintain a medication error rate below 5%, and this deficiency was cited again during the current survey. Specifically, the facility had an 8% medication error rate in one survey and a 6.45% error rate in the most recent survey, both exceeding the regulatory threshold. The QAPI Committee, which is responsible for ongoing monitoring and oversight, did not ensure that corrective actions were effective in preventing the recurrence of this deficiency. Observations during the survey revealed two medication errors out of 31 opportunities. One resident was not instructed to rinse with water after receiving a steroid inhaler, and another resident received an incorrect dosage of Thiamine. These errors were identified through direct observation, record review, and staff interviews. The facility's policy and previous history of citations for the same issue were also reviewed, confirming that the deficiency persisted despite prior interventions.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent a vulnerable resident from leaving the premises unsupervised. On the morning of March 22, 2025, a resident with a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment, was allowed to exit the facility through the front door by a transportation aide. The resident was left unsupervised on the porch and subsequently wandered off the premises. A Licensed Practical Nurse (LPN) encountered the resident in the parking lot and attempted to redirect them back to the facility. However, the LPN left the resident unsupervised to seek additional help. During this time, the resident moved further away and was found across the street in a daycare parking lot, approximately one-fourth of a mile from the facility. The resident was unsupervised and out of sight for approximately 13 minutes, which posed a significant risk to their safety. The facility's policy on wanderer management and resident elopement protocol was not effectively implemented, as all staff are responsible for ensuring resident safety. The incident was determined to be an Immediate Jeopardy and Substandard Quality of Care, as the resident's unsupervised departure put them and other vulnerable residents at risk for serious harm.
Removal Plan
- LPN #1 assisted the resident to return to the facility.
- The Administrator was notified by RN #1 of Resident#1 exited the building without supervision and was back in the building.
- Resident#1 was placed on 1:1 monitoring.
- Resident#1 Responsible Party was notified by the DON that Resident#1 exited and had been returned to the facility.
- Nurse Practitioner (NP)#1 was notified by the Director of Nursing of Resident#1 exit of facility and return along with behaviors. NP#1 placed an order for behavioral unit evaluation of Resident#1 for inpatient stay.
- DON contacted Behavior facility with a referral for resident#1 for further evaluation.
- Resident# 1 refused a head-to-toe assessment but LPN #2 was able to visually inspect resident#1 during incontinence care. No injuries were noted.
- Resident#1 exited the facility with Behavioral Unit for inpatient stay.
- The State Agency (SA) was notified by the Director of Nurses of the incident.
- The SOC initiated a 100%, mandatory In-service Training for elopement (including facility policy review) and the care of residents with difficult behaviors, to be continued for all new hires going forward. No staff are allowed to work until in service completed.
- The DON completed a post Elopement wander evaluation on Resident #1 and changed to high risk for Elopement, and the care plan was updated to reflect this.
- DON reviewed the wander and elopement binders to ensure all were up to date.
- A Quality Assurance Committee Meeting was held with the Medical Director, Administrator, Director of Nursing/Infection Preventionist, and the Assistant Director of Nursing to discuss Resident #1 elopement along with plan of correction; policies were reviewed with no revisions. The facility procedure for residents sitting outdoors was updated.
- The Director of Nursing audited current high-risk wander patients to review orders and care plans for accuracy. There was currently one (1) wander patient. And the Administrator performed an elopement drill.
- The Maintenance director performed elopement drills with staff to review and educate on policies and procedures on elopement.
- A Staff quiz was initiated by the CNA # 2 with all staff on knowledge of the elopement policy.
- Resident council meeting was held by the Administrator to include the President and 19 members to notify of current events and procedure changes to outdoor sitting with supervision in ungated areas.
- New procedures were implemented by the Administrator related to residents prohibited from sitting in ungated areas without supervision.
- New procedures were placed in the new hire orientation package by the Administrator for implementation of the procedure change of residents prohibited from sitting in ungated areas without supervision.
- Wander evaluations were audited by the Director of Nursing on all current residents reveals six residents requiring schedule adjustments.
- The Director of Nursing will monitor current residents for potential risks through incident report reviews, observation and communication with staff; the Maintenance Director will conduct elopement drills monthly (with rotating shifts until all shifts completed). The Administrator will present incident report reviews and documentation of drills for review to QA team weekly to monitor compliance with the plan then quarterly.
Resident Abuse by CNA in LTC Facility
Penalty
Summary
The facility failed to protect a resident from physical and emotional abuse by a Certified Nursing Aide (CNA). The incident occurred when the CNA handled the resident roughly, sprayed cold water on his face, and turned off the lights in the shower room while laughing. This behavior was witnessed by a Licensed Practical Nurse (LPN) who intervened during the shower to prevent further harm. The resident, who was cognitively intact, reported feeling sad, taken advantage of, and a little afraid due to the incident. The abuse took place on December 25, 2024, but was not reported to the Director of Nursing (DON) until December 30, 2024. During this period, the CNA continued to work at the facility, which placed the resident and others at risk of ongoing harm. The LPN who witnessed the incident reported it to the charge nurse and later to the Administrator, but there was a delay in the facility's response to the allegations. The previous Administrator was informed of the incident but did not take immediate action to suspend the CNA or report the abuse to the State Agency (SA). The facility's failure to act promptly and remove the CNA from duty resulted in a determination of Immediate Jeopardy and Substandard Quality of Care. The State Agency was notified of the situation on February 3, 2025, and the facility was found to be in compliance after implementing corrective actions. However, the delay in addressing the abuse and the continued employment of the CNA after the incident highlighted significant lapses in the facility's abuse prevention and reporting protocols.
Delayed Reporting of Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse within the required two-hour timeframe for one of the sampled residents. A Licensed Practical Nurse (LPN) witnessed physical and emotional abuse of a resident on December 25, 2024, but the facility did not report it to the State Agency until December 30, 2024. This delay in reporting increased the risk of further harm to the resident and other residents, potentially leading to serious injury, harm, impairment, or death. The incident involved a Certified Nursing Assistant (CNA) who handled a resident roughly during activities of daily living care. The CNA sprayed the resident in the face with cold water, turned off the lights in the shower room, and roughly shook the resident's bed. The resident, who was cognitively intact with a Brief Interview for Mental Status score of 14, was admitted to the facility with diagnoses including hypertension and depression. The LPN who witnessed the incident reported it to the charge nurse and the Administrator, but the report was not acted upon in a timely manner. Interviews revealed discrepancies in the reporting process. The LPN stated she reported the incident immediately to the charge nurse and later to the Administrator, who instructed her to write a statement. However, the charge nurse and other staff members did not confirm hearing the report. The Administrator, who was on vacation, claimed the LPN's verbal report differed from the written statement. The Director of Nursing was unaware of the incident until December 30, 2024, when corporate inquired about the report, leading to the delay in notifying the State Agency.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for three residents, resulting in strong urine odors and unsanitary conditions in their rooms. Observations revealed that Resident #2's room had a strong urine odor due to a wet incontinence brief found in the trash can. Despite noticing the odor before 11:00 AM, a CNA did not locate the source or notify housekeeping, allowing the smell to persist throughout the day. Similarly, the shared room of Resident #3 and Resident #4 was found to have a strong urine odor, with a urinal and spilled urine under Resident #3's bed. A CNA discovered a non-disposable incontinence pad that was wet and stained, emitting a strong odor of urine and feces, indicating that Resident #3 had been sitting in the soiled pad for an extended period. Interviews with facility staff, including the Assistant Housekeeping Supervisor and the Director of Nursing, confirmed the presence of strong urine odors and the need for immediate cleaning to maintain a safe environment. The Housekeeping Supervisor noted that the floor in the shared room needed significant cleaning and possibly tile replacement due to the persistent odor. The residents involved had various medical conditions, including cerebral infarction, chronic kidney disease, and cognitive deficits, which required assistance with personal hygiene and toileting. Despite these needs, the facility staff failed to provide timely and adequate cleaning, compromising the residents' right to a safe and comfortable living environment.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to implement comprehensive care plan interventions for two residents, leading to deficiencies in their care. For the first resident, the care plan required extensive assistance with personal hygiene and incontinence care to prevent skin breakdown. However, an observation revealed the resident was left in a saturated incontinence brief for an extended period, indicating a failure to provide timely care. The CNA responsible admitted to not checking on the resident for over two hours, despite the care plan's instructions to provide care with each incontinent episode. The second resident's care plan included interventions for managing incontinence and preventing falls, which were not followed. The resident was found sitting on a saturated incontinence pad with a strong urine odor in the room, and a pool of urine was observed under the bed. The CNA confirmed that the resident had not been checked for over three hours, contrary to the care plan's requirement for regular checks and assistance. Both residents were cognitively intact, as indicated by their BIMS scores, and required assistance with personal hygiene and toileting, which was not adequately provided.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for two residents, leading to deficiencies in care. Resident #2 was observed on a bedside mat with a saturated incontinence brief that had sagged to his lower thighs. The Certified Nursing Assistant (CNA) responsible for his care admitted to not checking on him between 11:00 AM and 1:29 PM, despite care instructions requiring checks every two hours. Resident #2, who was admitted in March 2020, had a history of cerebral infarction, repeated falls, and malignant neoplasm of the bladder. His Minimum Data Set (MDS) indicated he required moderate assistance for toileting hygiene and was frequently incontinent. Similarly, Resident #3 was found with a soaked incontinence pad during care provided by another CNA. The CNA confirmed that the last check was conducted at 1:00 PM, with no care provided until 3:47 PM. Resident #3, admitted in November 2021, had diagnoses including Stage 3 Chronic Kidney Disease and Benign Prostatic Hyperplasia. His MDS indicated substantial assistance was needed for personal hygiene and supervision for toileting. Interviews with staff, including a Registered Nurse and the Director of Nursing, confirmed that CNAs were expected to make rounds every two hours to meet residents' needs, which was not adhered to in these cases.
Failure to Maintain Safe Mechanical Lift Operations
Penalty
Summary
The facility failed to maintain mechanical patient care equipment in a safe operational condition, specifically for one of the six mechanical lifts. During an observation, a stand-up lift on the 100 Hall was found to be non-functional when its hand control buttons were pressed. Attempts to resolve the issue by replacing the battery were unsuccessful until a third battery from another lift was used, leaving that lift inoperable. Further investigation revealed that the lift only operated when the battery was manually squeezed into place, indicating a mechanical issue with the battery connection. Interviews with staff, including LPNs, CNAs, and the Maintenance Director, revealed a lack of communication and reporting regarding the malfunctioning lift. The Maintenance Director had not received any work orders for the lift, and the issue was not documented in the facility's maintenance management software, TELS. The Director of Nursing confirmed that equipment in need of repair should be removed from use and documented, but this procedure was not followed. The resident involved in the incident had a history of cerebrovascular disease, repeated falls, and malignant neoplasm of the bladder, and was cognitively intact at the time of the deficiency.
Failure to Notify Physician of Severe Pain
Penalty
Summary
The facility failed to notify the physician of a resident's severe pain, which was initially rated at a 10 on a pain scale of 0-10, for one of the sampled residents. Upon admission, the resident reported severe pain in her right hip, but did not receive any pain medication until later in the evening, hours after her arrival. The facility's policy required the nurse to inform the physician of the availability of remote medications in the facility when there is a change in condition likely to require medication. However, the nurse on duty did not notify the resident's primary healthcare provider about the resident's pain. The resident was admitted with diagnoses including aftercare following joint replacement, pain in the right hip, and the presence of a right artificial hip joint. Despite the resident's report of severe pain upon arrival, the nurse confirmed that no pain medication was administered on the day of admission, and there was no documentation of any report of unrelieved pain to the primary healthcare provider. The Director of Nurses and the Administrator confirmed the lack of notification to the healthcare provider, which was a deviation from the facility's pain management policy.
Failure to Administer Timely Pain Management
Penalty
Summary
The facility failed to provide timely pain management for a resident who reported severe pain upon admission. The resident, who had undergone a right total hip arthroplasty, arrived at the facility with a pain level of 9 out of 10 and had a physician's prescription for Oxycodone-Acetaminophen. Despite this, the resident did not receive any pain medication until several hours after arrival, with the first dose administered at 8:35 PM, over five hours after admission. Interviews with staff revealed that the nursing staff was aware of the resident's pain issues prior to admission, as communicated during a nurse-to-nurse phone report. However, the Licensed Practical Nurse (LPN) on duty did not administer any pain medication during her shift and did not recall the resident's report of pain. The Registered Nurse (RN) Supervisor conducted a pain assessment but did not administer medication, as she was not the medication nurse. Additionally, the RN did not notify the resident's primary healthcare provider about the unrelieved pain, nor was there any documentation of such communication. The Director of Nurses (DON) confirmed that the facility had policies in place for pain management, including the use of an Emergency Drug Kit (EDK) and notifying the primary healthcare provider if pain was unrelieved. However, these procedures were not followed, as there was no documentation of pain management interventions from 3:00 PM to 8:35 PM. The facility's Administrator was unaware that the prescribed medication was not administered as ordered, and the resident's complaints of unrelieved pain were not reported to the primary healthcare provider.
Failure to Follow Dialysis Aftercare Orders
Penalty
Summary
The facility failed to follow physician orders and dialysis aftercare communication for a resident requiring dialysis services. The resident, who was cognitively intact and dependent on renal dialysis due to Type 2 Diabetes Mellitus with Diabetic Chronic Kidney, was observed with a pressure dressing on his right forearm AV shunt from the previous day's dialysis session. Despite clear instructions to remove the dressing within a specified timeframe, the facility staff did not adhere to these orders, leading to the resident returning from dialysis with the dressing still in place. Interviews with the dialysis unit Facility Administrator and the Nurse Practitioner revealed ongoing communication issues between the dialysis unit and the facility. The dialysis unit had repeatedly stressed the importance of removing the pressure dressing to prevent damage to the resident's new access, but the facility staff failed to comply. The Director of Nurses acknowledged the responsibility of RNs and LPNs to maintain AV shunts and admitted that the facility did not follow up on conflicting messages from the dialysis unit regarding dressing removal times, resulting in inadequate care for the resident's AV shunt.
Incorrect MDS Coding for Resident Discharge
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for one of the sampled residents, Resident #126. The resident was admitted with diagnoses of acute kidney failure and Type 2 Diabetes Mellitus. Upon discharge, the MDS was incorrectly coded as a discharge to a short-term general hospital, while the resident was actually discharged to home with medications and home health services, including physical, occupational, and speech therapy. This discrepancy was identified through a review of the facility's records and confirmed by interviews with the staff. The MDS Coordinator and the Director of Nursing (DON) both acknowledged the error, confirming that the resident was discharged to live with her sister, not to a hospital. The MDS was coded by an LPN, and the MDS Coordinator did not verify the accuracy of the coding. The Administrator also expected the MDS Coordinator to ensure the correctness of the coding. This oversight led to the incorrect documentation of the resident's discharge status, which was not aligned with the facility's policy of utilizing the most up-to-date Resident Assessment Instrument (RAI) manual for accurate coding.
Failure to Conduct PASRR Level II for Resident with Mental Disorder
Penalty
Summary
The facility failed to ensure a Pre-Admission Screening and Resident Review (PASRR) Level II was obtained for a resident diagnosed with a serious mental disorder. The resident, who was admitted to the facility with a diagnosis of Paranoid Schizophrenia, initially came for short-term therapy and was later transitioned to long-term care. The Pre-Admission Screening (PAS) was completed upon admission for short-term care, but the necessary PASRR Level II screening was not conducted when the resident's status changed to long-term care. Interviews with facility staff revealed a lack of awareness and oversight regarding the need for a PASRR Level II screening. The Assistant Business Office Manager acknowledged that the PAS should have been updated when the resident's care status changed. The Administrator also confirmed that she was unaware of the requirement for a Level II PASRR referral upon the resident's transition to long-term care. The resident was cognitively intact, as indicated by a Brief Interview of Mental Status (BIMS) score of 15, but there was no documentation of a referral for the necessary PASRR Level II screening.
Medication Error Rate Exceeds 5% Due to Improper Eye Drop Administration
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in an 8% error rate. This was identified during a medication administration observation where a registered nurse (RN) administered two different eye drops to a resident without waiting the required three to five minutes between applications. The facility's policy, revised in January 2014, clearly states that when administering two or more different eye drops, a waiting period of three to five minutes is necessary to prevent one drop from washing out the other. However, the RN only waited 20 seconds between administering Prednisolone Acetate Ophthalmic Suspension and Ofloxacin Ophthalmic Solution to the resident. The resident involved had been admitted to the facility with diagnoses including total retinal detachment of the left eye and the presence of an intraocular lens. The resident had active physician orders for both eye drops to be administered four times a day following eye surgery. Despite having attended an inservice on medication procedures and guidelines, the RN did not adhere to the facility's policy during the administration. Interviews with the RN, the facility pharmacist, and the Director of Nursing confirmed the error and the importance of adhering to the waiting period between administering different eye drops.
Improper Handling of Dirty Linen by CNA
Penalty
Summary
The facility failed to adhere to its infection prevention and control policy regarding the handling and transportation of dirty linen. During an observation, a Certified Nursing Assistant (CNA) was seen carrying dirty linen against her clothes while walking down the hallway, instead of placing it in a leak-proof bag or container as required by the facility's policy. This action was confirmed by the CNA, who acknowledged that she should have used a plastic bag to prevent potential infection spread, but was unable to find one at the time. The Director of Nursing (DON) confirmed that the CNA's actions were against the facility's infection control policy and could potentially lead to infections among residents and staff. The CNA had previously been trained in infection control, as evidenced by an orientation checklist and a completion certificate for an eLearning course on infection prevention in long-term care settings. Despite this training, the CNA did not follow the proper procedures, leading to the deficiency noted in the report.
Failure to Revise Care Plans for Residents
Penalty
Summary
The facility failed to revise the care plans for two residents, leading to deficiencies in their care. For Resident #80, the care plan did not include interventions for the removal of the dialysis pressure dressing, despite multiple communications from the dialysis unit emphasizing the importance of timely removal to prevent damage to the resident's new access. Observations and interviews revealed that the facility did not update the care plan to reflect these instructions until after the State Agency's entrance, indicating a lack of communication and documentation by the nursing staff. For Resident #105, the care plan inaccurately reflected that the resident was receiving continuous tube feedings, although the physician's order had changed to bolus feedings five times a day due to the resident's tendency to unhook the feeding, posing a high risk for aspiration. Despite daily meetings intended to ensure care plans are updated with new orders, the care plan nurse confirmed that the care plan was not revised to reflect the new feeding order, highlighting a failure in the facility's process for updating care plans with current medical orders.
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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