Dermott City Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Dermott, Arkansas.
- Location
- 702 West Gaines St, Dermott, Arkansas 71638
- CMS Provider Number
- 045172
- Inspections on file
- 26
- Latest survey
- December 23, 2025
- Citations (last 12 mo.)
- 3 (1 serious)
Citation history
Health deficiencies cited at Dermott City Nursing Home during CMS and state inspections, most recent first.
A CNA transferred a resident without using the required mechanical stand-up lift or a second staff member, contrary to the care plan. After the resident fell and complained of pain, two CNAs moved the resident to a wheelchair before a nurse assessment. The resident, who had a history of falls and required two-person assist for transfers, sustained an acute femoral fracture requiring surgery. Staff interviews confirmed the care plan and post-fall protocols were not followed.
The facility did not have a Licensed Administrator overseeing daily operations for several months after the previous Administrator resigned. During this period, administrative duties were not properly fulfilled, with a Compliance Officer—who lacked the required Administrator's license—listed as interim Administrator on official reports, including those related to a resident injury. The facility had not interviewed any candidates for the position and was still seeking a replacement.
A resident with cognitive impairment and mobility deficits, care planned for two-person assistance with a mechanical stand-up lift for transfers, was transferred by a CNA without the required lift or second staff member. During the transfer, the resident fell and sustained a right femur fracture. Staff interviews confirmed the care plan was not followed, and the facility's policy requires adherence to care plan interventions.
The facility did not post required daily staffing information, including total hours worked by RNs, LPNs, CNAs, and resident census. Observations showed incomplete or missing logs, and interviews revealed a lack of training and clarity on responsibilities for posting this information.
The facility failed to serve meals according to the planned menu, affecting residents on mechanical soft diets. During lunch, a dietary staff member used an incorrect scoop size for pureed chicken and dumplings, and the kitchen ran out of cornbread, substituting regular bread. At supper, pureed baked beans were not served due to cross-contamination, and residents received alternative items instead.
The facility's dietary department failed to maintain proper food safety and hygiene practices. Staff did not wash hands or change gloves before handling food, and several food items were improperly stored or expired. Additionally, hot food items were served below the required temperature, violating the facility's policy on preventing foodborne illness.
A resident with memory problems and requiring total assistance for repositioning was observed multiple times without a pillow, leading to discomfort and improper neck alignment. Staff interviews confirmed the resident's dependency on staff for positioning and the absence of a pillow, despite another resident having two pillows. The facility's policy emphasized the importance of comfort and proper positioning.
A resident with multiple medical conditions, including hemiplegia and osteoporosis, was injured during a transfer when an RN attempted to move them alone, contrary to the care plan requiring two staff and a mechanical lift. The RN was not adequately trained on accessing the care plan, leading to the resident's fall and subsequent leg fracture.
The facility failed to operate under the direction of a licensed Administrator, affecting all 45 residents. The Acting Administrator, who was the Compliance Coordinator, confirmed that the previous Administrator had been absent since July and that she did not hold a nursing home administrator's license. Documentation assigning her as Acting Administrator was undated and unsigned. The facility's policy requires the Administrator to be licensed and responsible for the facility's day-to-day functioning and resident care policies.
Failure to Follow Transfer Protocols and Post-Fall Assessment Leads to Resident Injury
Penalty
Summary
Certified Nursing Assistants (CNAs) failed to demonstrate competency in the care of a resident by not following the resident's care plan and by moving the resident prior to a nurse assessment following a fall. Specifically, one CNA attempted to transfer a resident from bed to wheelchair without using the required mechanical stand-up lift and without a second staff member to assist, as mandated by the resident's care plan. During this improper transfer, the resident's legs gave out, resulting in the resident falling to their knees on the floor. After the fall, the CNA requested assistance from another CNA, and together they moved the resident from the floor to a wheelchair before the resident was assessed by a nurse, despite the resident complaining of pain. Both CNAs admitted in interviews that moving the resident prior to a nurse's assessment was not appropriate. The resident was later found to have sustained an acute right femoral fracture, which required surgical intervention. The resident involved had a history of scoliosis, unsteadiness on feet, dementia, and was care planned for transfers with a mechanical stand-up lift and two-person assist due to dependency in activities of daily living and a recent history of falls and fractures. Staff interviews and record reviews confirmed that the care plan was not followed, and the required protocols for post-fall assessment were not adhered to, resulting in significant harm to the resident.
Removal Plan
- All licensed nursing staff and certified nursing assistants will be in-serviced by the Director of Nursing (DON)/designee on the proper steps taken after a resident has sustained a fall, to prevent serious harm, serious injury, serious impairment, or death.
- All Certified Nursing Assistants (CNAs) and licensed nurses will be educated and in-serviced by the DON/designee on proper resident transfers to prevent serious harm, serious injury, serious impairment or death.
- All CNAs and licensed nurses will be educated and in-serviced by the DON/designee on locating and reviewing the care plan prior to resident care and implementing the care plan during resident care to prevent serious harm, serious injury, serious impairment, or death.
- All licensed nurses and CNAs will be educated to check the Kardex /plan of care, located in the kiosk, on a resident and implement it, also the proper steps to take after a resident sustain a fall, and to be educated on the proper transfer technique to prevent serious harm, serious injury, or death.
- The DON/designee will visually monitor residents being transferred, visually monitor licensed nurses and certified nurse assistants on locating, reviewing the plan of care, and implementing the plan of care, also proper steps taken when a resident sustains a fall, by CNA, and licensed staff, to prevent serious harm, serious injury, or death 5 times a week for 8 weeks or until compliance is verified by Office of Long-Term Care.
- The DON/designee will present all findings to the monthly QAPI (Quality Assurance & Performance Improvement) committee for further review and recommendations.
Failure to Employ Licensed Administrator for Facility Oversight
Penalty
Summary
The facility failed to ensure that a Licensed Administrator was hired to oversee the day-to-day operations in accordance with federal, state, and local regulations. Review of the Administrator job description and facility policy confirmed that the position requires a current, unencumbered Administrator's license and that the governing body is responsible for ensuring proper management and oversight. However, interviews and documentation revealed that the facility had been without a licensed Administrator since the previous Administrator resigned in July 2025. The Compliance Officer, who was listed as the interim Administrator on official reports, confirmed she did not hold an Administrator's license and was not acting in that capacity. Further review of incident reports indicated that administrative duties were not being properly fulfilled, as evidenced by the Compliance Officer's name being listed in the Administrator's section of an incident report involving a resident injury. Interviews with the Director of Nursing and Human Resources confirmed that no one had been filling the Administrator role and that no candidates had been interviewed for the position since the resignation. The facility was actively advertising for the position but had not yet hired a replacement.
Failure to Implement Care Plan for Safe Resident Transfer
Penalty
Summary
The facility failed to consistently implement a comprehensive care plan for a resident with multiple diagnoses, including scoliosis, unsteadiness on feet, dementia, and a history of fractures and falls. The resident was assessed as having moderate cognitive impairment and required staff assistance for activities of daily living, including transfers, for which the care plan specified the use of a mechanical stand-up lift with two staff members. Despite this, on the day of the incident, a CNA attempted to transfer the resident without the stand-up lift and without a second staff member, resulting in the resident falling to the floor. The incident occurred when the CNA, believing the resident could bear weight and pivot, assisted the resident from bed to wheelchair without following the care plan's specified interventions. During the transfer, the resident's shoe slipped, causing the resident's legs to give out and leading to a fall. The CNA admitted to not using the stand-up lift and was uncertain if she had reviewed the care plan prior to providing care that day. Other staff, including another CNA and an LPN, confirmed that the resident was care planned for two-person assistance with a stand-up lift and that this protocol was not followed during the incident. As a result of the improper transfer, the resident sustained an acute fracture of the right femur, confirmed by radiology and requiring orthopedic consultation. Interviews with facility staff, including the DON and compliance officer, revealed that staff are expected to review and follow care plans for all residents, particularly regarding transfer methods. The facility's policy requires that care plan interventions be implemented as written, but in this case, the specified transfer protocol was not followed, directly leading to the resident's injury.
Failure to Post Required Daily Staffing Information
Penalty
Summary
The facility failed to ensure that the required staffing data was posted daily, as evidenced by the absence of total number and actual worked hours for RNs, LPNs, CNAs, and the resident census on the daily staffing logs. Observations on multiple days revealed that the staffing logs did not display the necessary information, such as the total hours worked by staff and the resident census. The logs were either incomplete or missing for certain shifts and days, and the information was not visible to the public as required. Interviews with the DON, LPN, BOM, and HR revealed a lack of clarity and training regarding the responsibilities for filling out and posting the staffing logs. The DON indicated that the night shift nurse was responsible for placing the sheets out, but there was no confirmation that the nurse was trained on what information needed to be included. The LPN and HR staff also confirmed that they had not been instructed to include the total hours worked or the census on the logs. The BOM and HR used the census sheet for internal purposes but did not ensure it was publicly posted as required.
Failure to Adhere to Planned Menu and Serve Nutritional Meals
Penalty
Summary
The facility failed to ensure meals were prepared and served according to the planned written menu, impacting the nutritional needs of residents on mechanical soft diets. During lunch, a dietary staff member used a #8 scoop instead of the required #6 scoop to serve pureed chicken and dumplings, resulting in smaller portions than specified. The staff member admitted to not consulting the menu before serving. Additionally, the kitchen ran out of cornbread and substituted regular bread for seven residents because the dietary staff prioritized feeding employees first. During supper, residents on pureed diets did not receive pureed baked beans as planned. The dietary manager explained that the beans were discarded due to cross-contamination when a scoop fell into the prepared beans after being handled with a contaminated glove. Instead, residents were served mashed potatoes, pureed corn dogs, and tomato juice. These actions and inactions demonstrate a failure to adhere to the planned menu and ensure the nutritional needs of residents were met.
Food Safety and Hygiene Deficiencies in Dietary Department
Penalty
Summary
The facility failed to adhere to proper food safety and hygiene practices, as observed during a survey. Dietary staff did not wash their hands or change gloves before handling food items, leading to potential contamination. For instance, a dietary staff member touched a box of plastic sheets and then handled glasses by their rims without washing hands. Another staff member handled various food items and equipment without changing gloves after touching potentially contaminated surfaces. Food storage practices were also found to be inadequate. Several opened boxes of food items in the walk-in refrigerator and freezer were not covered or sealed, including bacon, catfish patties, hamburger patties, and more. Additionally, expired food items, such as a container of cottage cheese, were not promptly removed from stock. An ice scoop holder was found with a black and beige residue, indicating a lack of cleanliness in the kitchen area. Furthermore, the facility did not maintain hot food items at the required temperature of 135 degrees Fahrenheit or above. Pureed chicken and dumplings, green beans, and bread with warm milk were served at temperatures below the standard. Similarly, chicken and dumplings and ground corn dogs were served at inadequate temperatures later in the day. These deficiencies highlight a failure to follow the facility's policy on preventing foodborne illness through proper employee hygiene and sanitary practices.
Failure to Provide Appropriate Bedding for Resident
Penalty
Summary
The facility failed to provide appropriate bedding for a resident who was observed multiple times without a pillow. The resident, who had short-term and long-term memory problems, required total assistance to turn and reposition in bed and was unable to voice discomfort or desired positioning. Observations by the surveyor on different occasions revealed the resident lying in bed without a pillow, using their hand or the mattress to support their head, which was noted to cause a bend in the neck. Interviews with facility staff, including a CNA and an LPN, confirmed that the resident was not capable of positioning themselves and was dependent on staff for assistance. The LPN acknowledged the absence of a pillow and noted that another resident in the room had two pillows. Both the Administrator and the Director of Nursing confirmed that the resident was unable to position themselves and that the lack of a pillow could affect the resident's neck posture. The facility's policy on repositioning emphasized the importance of promoting comfort and preventing skin breakdown, circulation issues, and pressure relief for residents.
Failure to Follow Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to safely transfer a resident in accordance with their care plan, resulting in a major injury. The resident, who had diagnoses including renal osteodystrophy, cerebral infarction, hemiplegia, and osteoporosis, was dependent on two staff members for transfers and required a mechanical lift. However, a Registered Nurse (RN) attempted to transfer the resident alone, without using the required lift, leading to the resident missing the wheelchair and being lowered to the floor. This incident resulted in a non-displaced fracture to the resident's right proximal tibia and fibula. The RN involved in the incident was not adequately trained on accessing the resident's care plan and Kardex, which would have informed her of the necessary interventions for safe transfers. Despite being in-serviced on using the kiosk, the RN admitted to not knowing how to use it and relied on instincts during the transfer. The Director of Nursing stated that all staff are trained during orientation and receive annual in-services, but the RN's lack of knowledge indicates a gap in training effectiveness. The facility's policy on fall prevention was not adhered to, as the resident was not evaluated for risk of falls, and successful interventions were not continued to prevent the incident.
Facility Lacks Licensed Administrator
Penalty
Summary
The facility failed to operate under the direction of a licensed Administrator, which had the potential to affect all 45 residents residing in the facility. On October 21, 2024, a surveyor was informed by the Director of Nursing (DON) and the Acting Administrator, who was the Compliance Coordinator, that no licensed Administrator was currently employed at the facility. The Acting Administrator confirmed that the previous Administrator had been absent since July 15, 2024, and the position had been posted on employment websites. However, the Acting Administrator did not hold a nursing home administrator's license. Furthermore, when asked for documentation assigning her as Acting Administrator, she provided an undated typed document without a name or signature of the person who assigned her the position. A review of the facility's policy titled 'Administrator' revealed that the Administrator is responsible for the day-to-day functioning of the facility, implementing established resident care policies, ensuring residents' rights, ensuring adequate staffing to meet residents' needs, and ensuring that only residents who can be adequately cared for by staff are admitted. The policy also stated that the Administrator must be duly licensed in accordance with federal, state, and local laws.
Latest citations in Arkansas
A resident with peripheral vascular disease, prior toe amputation, and malnutrition had multiple lower extremity wounds managed by an external Wound Care Clinic, which issued detailed written orders for cleansing, specific dressings, and compression. Facility TAR entries showed generalized leg treatments on a fixed schedule instead of the ordered every-other-day frequency, did not distinguish between multiple wounds on the same leg, omitted documentation of ordered transfer foam and a compression stocking, and added self-adherent wrap that was not ordered. Interviews with the TN and DON confirmed that the TN was responsible for entering and carrying out clinic orders, and leadership could not produce documentation that all ordered treatments were provided or explain the altered treatment frequency, contrary to facility policy requiring treatments to follow provider orders.
Surveyors found that a nurse responsible for wound care and infection prevention failed to follow basic infection control practices while treating two residents with pressure ulcers and one with a suprapubic catheter. The nurse repeatedly handled keys, a phone, and a computer, then accessed and prepared wound supplies without performing hand hygiene, touched gauze with ungloved hands before using it on a wound, and set up supplies on non‑impervious paper towels next to personal items instead of on a properly disinfected, protected surface. During one observation, the nurse cleaned a hip pressure ulcer and then a suprapubic catheter site using separate gauze cups but without changing gloves or performing hand hygiene between dirty and clean tasks, and then applied dressings after glove removal without washing hands. Facility policies required clean technique, use of an impervious barrier, handwashing between dirty and clean steps, and labeling dressings, but these were not followed, and the nurse and leadership acknowledged that the nurse had not received formal wound care training from the facility.
Two residents with complex medical conditions and extensive medication regimens experienced significant medication errors when new LPNs, inadequately oriented and not fully competency-checked, misadministered drugs during med pass. In one case, a new LPN on her first day, unfamiliar with residents and the electronic system, gave another resident’s medications—including a hypoglycemic and an antihypertensive—to a cognitively intact resident with multiple cardiopulmonary and renal diagnoses, leading to hypotension, hypoglycemia, and hospital transfer. In the other case, an LPN in training and her preceptor pulled medications simultaneously from the same cart, and a resident requesting pain medication received an excessive dose of a controlled sleeping pill instead, a drug the pharmacist stated would definitely increase sedation and could depress CNS and breathing. Facility policy required verification of resident identity, triple-checking medication labels, and at least three days of accompanied med rounds for new personnel, but interviews showed these requirements were not fully implemented before the new nurses participated in or conducted medication administration alone or in a hurried, shared-cart process.
The facility failed to implement and complete its nurse orientation and competency validation process for new LPNs, resulting in two separate medication errors. One LPN, new to LTC and unfamiliar with the facility’s computer system, was left alone on the med cart after only partial observation-based training and without a completed competency checklist, and a resident received another resident’s medications. Another new LPN, also without documented competency sign-offs, was in joint med-pass with an untrained preceptor when a resident requesting pain medication was given sleeping pills after the preceptor pulled the wrong controlled medication and the trainee administered it. Preceptors were selected informally from floor nurses without preceptor training, and leadership interviews confirmed that required competency checklists and the facility’s own med-pass orientation policy were not consistently followed or documented.
Two residents who required substantial/maximal assistance with ADLs did not receive consistent nail care, use of protective geri-sleeves, and shaving as outlined in their care plans. One resident with Parkinson’s disease, severe cognitive impairment, and a history of arm skin tears was repeatedly observed with overgrown fingernails and exposed arms without geri-sleeves, despite ADL records indicating weekly nail checks and encouragement of geri-sleeves. Staff interviews revealed uncertainty about who was responsible for applying geri-sleeves and providing nail care, and ADL documentation lacked staff initials. Another resident with tremors and moderate cognitive impairment was observed multiple times with visible chin hair and reported not being offered shaving, even though ADL records showed facial hair checks and shaving as needed were documented as completed without initials. A CNA acknowledged seeing the facial hair earlier and intending to shave the resident later, and the DON confirmed CNAs were responsible for checking and removing facial hair and that documentation should not indicate tasks were done when they were not.
A resident with respiratory failure, heart failure, type 2 diabetes, and COPD was approved to self-administer inhaled medications, but surveyors observed the resident’s corticosteroid and beta2-agonist inhalers left unattended on the over-bed table on multiple occasions, and a medication lockbox kept on the over-bed table with the key left in the lock. The resident reported being told they could use their own inhalers. An LPN stated the resident was approved for unsupervised self-administration but admitted not being familiar with the self-administration policy, while also acknowledging that medications should not be left on the over-bed table and that the lockbox should not have the key in it. The DON and another LPN described that the facility’s process and expectations required assessment of the resident’s ability to self-administer, demonstration of correct use, and secure locked storage out of reach of other residents, and CNAs stated that medications should not be left out in resident rooms.
A resident with terminal Parkinson’s disease and severe cognitive impairment was enrolled in hospice, with hospice aides providing baths and an updated care plan specifying hospice CNA, RN, social services, and chaplain visits. However, no hospice physician order was present in the EHR at the time, no hospice notes appeared in progress notes, and the MDS still reflected that the resident was not on hospice. The MDS Coordinator reported she did not complete a Significant Change in Status Assessment because there was no hospice order in the system to trigger it, later finding that the hospice admission order had been dated earlier but not entered until much later. The DON stated that the nurse on duty at hospice admission should have entered the hospice order and believed nurses knew they were responsible for doing so.
A nonverbal resident with a history of brain stem hemorrhage and intact cognition was admitted with documented unclear speech, rare ability to make themself understood, and reliance on nodding, head shaking, and sign language for communication, yet no communication deficit with individualized interventions was initiated on the comprehensive care plan. Multiple assessments and progress notes by nursing, social services, APRN, and SLP consistently described the resident as nonverbal and using alternative communication methods, but these findings were not incorporated into a person-centered care plan. CNAs, an RNA, and an LPN reported using yes/no questions, body language, facial cues, and the resident’s hand signals to communicate, while also stating they did not know sign language and had not seen communication boards or structured tools, and leadership acknowledged that a communication deficit should have been care planned and that there were no facility policies guiding communication care planning for nonverbal residents.
A resident with neuropathy, non‑weight‑bearing status on one leg, multiple comorbidities, and a known history of falls was care planned as high fall risk and required two‑person assistance with a gait belt for all transfers. After prior incidents where the resident’s legs had given out during transfers, two staff attempted a wheelchair‑to‑toilet transfer by standing and pivoting the resident using the stronger leg while the resident held grab bars, but they did so without a gait belt. The resident’s legs collapsed, the resident went down to the knees, and an abrasion to the knee occurred. Staff and leadership interviews, along with policies and job descriptions, confirmed that a gait belt was required for all assisted transfers and that staff were expected to follow this procedure, but the involved staff admitted they forgot to use the gait belt during this transfer.
A resident with respiratory failure and other comorbidities received O2 via nasal cannula under an order that lacked a start date and was not set up as a scheduled order in the electronic record, even though oxygen use was documented on multiple days. Over several days, the resident’s humidifier bottle was repeatedly observed to be undated or dated but empty while the resident was on 2 L O2, and the resident reported persistent nasal dryness and that the bottle had been empty despite asking staff to change it. An LPN confirmed the order issue and acknowledged the empty, dated humidifier bottle, and leadership reported expectations for changing tubing and humidifier bottles but had no policy addressing oxygen equipment or humidified water.
Failure to Follow Wound Clinic Orders for Lower Extremity Wounds
Penalty
Summary
The deficiency involves the facility’s failure to complete and follow wound care provider orders for one resident with multiple lower extremity wounds. The resident was admitted with diagnoses including peripheral vascular disease, acquired absence of a right toe, and malnutrition, and was documented as alert, oriented, and cognitively intact. The resident received wound care at an external Wound Care Clinic, which issued detailed written orders on two separate dates for multiple wounds on both lower legs, specifying cleansing with normal saline, use of transfer foam or autolytic debridement gel, specific secondary dressings, soft cloth surgical tape, sterile roll gauze, gauze sponges, and, for one right lower leg wound, a compression stocking. Review of the facility’s Treatment Administration Record (TAR) for the same period showed that the treatments documented did not match the clinic’s orders. The TAR listed generalized treatments for the left and right lower legs, including cleansing with normal saline, gauze to the wound bed, and application of self-adherent wrap from toes to bend of leg on a Tuesday, Thursday, Saturday schedule, rather than every other day as ordered. Later TAR entries for bilateral extremities referenced autolytic debridement gel, auto debridement dressing, and elasticated tubular bandage, but still did not clearly distinguish between the multiple wounds on the right lower leg or document all ordered components. There was no distinction on the TAR to ensure both right lower leg wounds were treated, no documentation that transfer foam was applied as ordered, and no documentation that the ordered compression stocking was applied to the specified right lower leg wound. Interviews and record review confirmed these discrepancies and the lack of supporting documentation. The Treatment Nurse described a process in which Wound Care Clinic orders were faxed to the facility, compiled, and then entered onto the TAR by the Treatment Nurse after leadership meetings or by the end of the business day. The DON stated that it was the Treatment Nurse’s responsibility to ensure clinic orders were completed and acknowledged that wounds could deteriorate if not treated per provider orders. During a joint interview, the DON, Administrator, and Nurse Consultant were unable to provide any documentation that the transfer foam treatment was given as ordered or any explanation for why every-other-day orders were carried out on a fixed Tuesday, Thursday, Saturday schedule. Facility policy on Medication and Treatment Orders required that medications be administered per the written order of a licensed provider, which was not followed in this case.
Inadequate Hand Hygiene and Aseptic Technique During Wound and Catheter Care
Penalty
Summary
The deficiency involves the facility’s failure to provide wound care in a manner that prevented infection for two residents receiving wound treatments. For the first resident, who had cellulitis, type 2 diabetes mellitus, protein-calorie malnutrition, venous insufficiency of both lower extremities, chronic venous hypertension with inflammation, candidiasis of the skin and nails, and a stage 2 pressure ulcer to the sacrum, the Treatment Nurse (TN), who was also the Infection Preventionist (IP), did not consistently perform hand hygiene or maintain a clean field. During wound care, the TN handled personal items such as keys, a cell phone, and the computer, then accessed wound care supplies from the treatment cart without performing hand hygiene afterward. The TN touched gauze pads with ungloved hands, sprayed them with wound cleanser, and later used those same gauze pads to cleanse the resident’s wound. The TN also set up supplies on a bathroom counter using a non‑impervious paper towel as a barrier, contrary to facility policy requiring an impervious barrier, and did not date or initial the new dressing. For the second resident, who had diagnoses including congestive heart failure, protein-calorie malnutrition, hypertension, GERD, neuromuscular bladder dysfunction, a stage 3 pressure ulcer of the right hip, urethrocutaneous fistula, UTI, and an indwelling catheter, the TN again failed to follow infection prevention practices during wound care. The TN unlocked the treatment cart with keys from her pocket, returned the keys to her pocket, and touched the computer before retrieving wound care supplies, then proceeded without performing hand hygiene until later in the process. She prepared gauze pads in cups with wound cleanser while gloved, then removed her gloves and continued the setup. In the resident’s room, she cleaned only half of the bedside table with a wet, soapy paper towel and dried it with another towel, then placed a non‑impervious paper towel as a barrier for wound supplies, while the other half of the table remained cluttered with personal items including a basin with cups and straws hanging over the wound supplies. During the wound care for the second resident, the TN washed her hands in the bathroom for approximately six seconds before donning gloves. She removed the old dressing from the right hip pressure ulcer, changed gloves, and then used gauze from one cup to clean the hip pressure ulcer. Without performing hand hygiene or changing gloves between dirty and clean tasks, she then used gauze from a second cup to clean the resident’s suprapubic catheter site, which she stated had drainage and had been cauterized the previous week. After removing her gloves, she did not perform hand hygiene before placing a split drain gauze around the suprapubic catheter and applying calcium alginate and a bordered foam dressing to the right hip wound. The TN later acknowledged that she did not wash her hands when going from dirty to clean tasks, that she should have changed gloves before moving to the secondary dressing, and that she had not received wound care training from the facility despite functioning as the wound care nurse and IP. Facility policies required clean technique, prevention of supply and surface contamination, use of an impervious barrier, handwashing after removing dirty gloves and before donning clean gloves, and labeling new dressings with initials, date, and time, as well as adherence to handwashing guidelines consistent with CDC recommendations for at least 15 seconds of rubbing. Interviews with the TN, Nurse Practitioner (NP), and Director of Nursing (DON) further clarified the expectations and deviations from practice. The TN stated she believed she performed hand hygiene when entering rooms and after touching anything dirty, but acknowledged she did not wash her hands between dirty and clean tasks and recognized that setting up wound supplies next to personal items would be an infection control issue. The NP stated that the suprapubic catheter and pressure ulcer should be cleaned one at a time and not treated simultaneously, and that she would not want wound contaminants introduced to the suprapubic catheter. The DON reported that the TN had been performing wound care since around November, had no wound care certification, and had received no specific wound care training from the facility, although the DON believed the TN had prior wound care experience elsewhere. The DON stated that staff should clean hands and change gloves when going from dirty to clean tasks, that separate areas such as a suprapubic catheter and a pressure ulcer should not be treated at the same time due to infection concerns, that dressings should be dated as a standard practice, that bedside tables should be clean, uncluttered, and disinfected rather than just washed with soap and water, and that a brief six‑second handwash was not appropriate.
Failure to Prevent Significant Medication Errors for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to prevent significant medication errors for two residents during medication administration. For the first resident, who had multiple complex diagnoses including pneumonia, COPD, CHF, atrial fibrillation, pulmonary hypertension, peripheral vascular disease, chronic kidney disease stage 3, hypertension, hyperlipidemia, and aortic valve stenosis, a nurse on her first day at the facility administered another resident’s medications in error. The resident was cognitively intact and receiving numerous scheduled medications, including diuretics, anticoagulants, antihypertensives, electrolyte replacements, and oxygen. A Medication Error Report documented that the resident was mistakenly given four incorrect medications intended for another resident, including a blood sugar–lowering medication, an antidepressant, a uric acid–lowering medication, and an antihypertensive with side effects of hypotension and hyperkalemia and label warnings related to diabetic medications. The error for the first resident occurred when an LPN, new to LTC and to the facility’s computer system, misidentified the resident and pulled the wrong medications. The LPN reported that it was her first day, she had limited orientation time with an RN preceptor that morning, and she had not been checked off as competent to administer medications independently. She stated she did not yet know the residents, found the electronic photos too small to distinguish individuals, and did not know how to enter orders into the computer. She described feeling overstimulated and attempting to work independently. The UM, who was simultaneously functioning as wound nurse, UM, and preceptor, left the LPN alone on the cart after the LPN stated she felt comfortable, despite the UM not having observed her passing medications and not having completed the medication portion of the competency checklist. The RN who precepted earlier in the day stated the LPN had only observed her, had not performed tasks independently, and had not been checked off to administer medications alone. Following the wrong-medication administration to the first resident, vital signs later showed hypotension and hypoglycemia, and the resident was sent to the hospital. Hospital records documented treatment for a medication error, hypotension, hypoglycemia, elevated heart enzymes, and acute kidney injury, with very low blood pressure on arrival and the resident reporting feeling like they were dying. Documentation from the hospital indicated facility staff reported the resident had been hypotensive for two hours. The pharmacist, after reviewing the resident’s scheduled medications and the medications given in error, stated she would have monitored for low blood pressure, low blood sugar, and oversedation, and identified multiple medications that could contribute to these effects. The NP stated it was difficult to determine whether the medication error caused the event, noting the resident’s existing pneumonia and kidney function issues. The resident’s representative reported being notified of a severe drop in blood pressure and stated that a physician advised seeking legal advice. The second resident involved in the deficiency had multiple diagnoses including critical illness myopathy, metabolic encephalopathy, cerebral edema, diabetes, morbid obesity, respiratory failure with hypoxia and hypercapnia, obstructive sleep apnea, cognitive communication deficit, dysphagia, hyperlipidemia, bipolar disorder, hypertension, and chronic kidney disease, and was cognitively intact. This resident was on a complex medication regimen including antipsychotics, antidepressants, anticoagulants, antibiotics, diuretics, opioids, and hypoglycemics. A Medication Error Report documented that the resident was accidentally given two sleeping pills instead of two pain pills. The error occurred while an LPN in training and her preceptor were both pulling medications from the same cart, with the trainee pulling non-controlled medications and the preceptor pulling narcotics. For the second resident, the trainee LPN reported that the resident had requested a pain pill but was given sleeping pills instead. She stated that the mistake was discovered later when controlled medications were counted and that the sleeping pill, a controlled medication, was stored in the narcotic box with other controlled medications. She reported that the preceptor punched the medication from the wrong card, that the pills were both small white tablets, and that they were trying to hurry. The trainee LPN stated she did not recall any specific competency check-offs and that her license had simply been verified. The pharmacist stated that the dose of sleeping medication given exceeded the recommended daily dose and would definitely increase sedation, with potential for amnesia, CNS depression, and breathing interruptions if the resident did not use a pressurized mask while sleeping, as well as possible sleepwalking episodes. The NP later reported there were no adverse side effects observed in this resident. The facility’s written Medication Administration policy required that medications be administered in accordance with orders, that the individual administering medications verify resident identity before administration, and that the label be checked three times to ensure the right resident, medication, dose, and route. The policy also stated that medications ordered for one resident may not be administered to another, and that new personnel authorized to administer medications would not be permitted to prepare or administer medications until oriented to the facility’s medication administration system. It further required that a charge nurse accompany new nursing personnel on medication rounds for a minimum of three days to ensure procedures were followed and proper resident identification methods were learned. Interviews with the UM, RN preceptor, and LPNs indicated that the new nurses involved in both medication errors were allowed to participate in or conduct medication passes without full completion of competency checklists, without consistent direct observation, and while preceptors were performing multiple roles or sharing the cart, contributing to the misadministration of medications to both residents.
Failure to Implement Effective Nurse Orientation and Competency Validation Leading to Medication Errors
Penalty
Summary
The deficiency involves the facility’s failure to implement an effective nurse training and competency program for new LPN staff, resulting in incomplete orientation and unverified competencies for at least two nurses. The facility maintained a New Trainee Folder and a Licensed Nurse Competency Skills Check-off form intended to cover unit safety, communication, infection control, nursing care, emergency procedures, equipment, medication administration, pain management, resident rights, abuse, dementia care, QAPI, person-centered care, cultural competency, and HIPAA. Human Resources reported that the competency checklist was to be printed and placed in a staffing binder, completed by the preceptor over the first three days, and then signed off by leadership. However, for both reviewed LPNs, these competency checklists were not completed, and there was no documented verification that they had met medication administration or other required competencies before functioning independently. One LPN, on her first day working in the facility and with no prior LTC experience, was involved in a medication error in which a resident received another resident’s medications. This LPN reported that she had only been trained by an RN from 6 AM to 10 AM on how residents took their medications and who had swallowing issues, and that she did not know how to enter orders into the computer system and was unfamiliar with the software. The RN preceptor stated that the LPN had only observed her and had not performed any tasks independently before the RN left, and that she had not checked the LPN off to administer medications alone. The Unit Manager acknowledged that the LPN had no LTC experience, that she did not complete the medication portion of the competency checklist, and that she left the LPN alone on the cart after the LPN stated she felt comfortable, despite not having seen her pass medications. The facility’s Medication Administration policy required that new personnel not administer medications until oriented to the system and that a charge nurse accompany them on medication rounds for a minimum of three days, but this process was not followed or documented for this LPN. Another new LPN, also without a completed competency checklist, was involved in a separate medication error in which a resident requesting pain medication received sleeping pills instead. This LPN reported that she was in training with a preceptor, and that both nurses were pulling medications from the same cart, with the preceptor handling controlled substances. The error occurred when the preceptor punched a sleeping pill from the wrong card, and the trainee LPN administered it, noting that the pills were both small and white and that they were trying to hurry. The LPN stated she did not recall any specific competency check-offs being done beyond a license check. The Unit Manager and ADON both confirmed that preceptors were simply floor nurses who had been at the facility longer, with no formal preceptor training, and that the current training program had only recently started. Employee files for both LPNs lacked completed Licensed Nurse Competency Skills Check-off forms as of the survey date, and leadership interviews showed uncertainty about when competency checklists should be completed and how much training the LPNs had actually received before being allowed to function independently.
Failure to Provide Regular Nail Care, Protective Sleeves, and Shaving for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide regular nail care and use of protective geri-sleeves for one resident and shaving/personal grooming for another resident, as required by their care plans and ADL needs. For Resident #91, surveyors observed on multiple occasions that the resident’s fingernails extended over the tips of the fingers, despite a care plan intervention directing staff to check nail length and trim and clean nails on bath day and as necessary. The resident had Parkinson’s disease with dyskinesia, severe cognitive impairment (BIMS score of 04), required substantial/maximal assistance with showering and personal hygiene, and had a history of skin tears on the right arm. The care plan also included an intervention to encourage use of geri-sleeves due to potential skin integrity impairment, but the resident was repeatedly observed with arms exposed and without geri-sleeves in place. Record review for Resident #91 showed ADL tasks for checking, cutting, and filing nails weekly, and for encouraging geri-sleeves as tolerated, were marked as completed on several dates; however, there were no staff initials to identify who performed these tasks. During interviews, CNAs and a MA-C demonstrated uncertainty about who was responsible for placing geri-sleeves on the resident, when they should be applied, and whether the resident was supposed to wear them at all. One CNA believed hospice aides provided nail care and that they visited three times a week, while another CNA stated she provided nail care when needed and that the resident did not wear geri-sleeves, even though she acknowledged the resident would need them due to fragile skin. The DON reported there was no facility policy for ADLs and did not provide skills check-offs for the CNAs involved. For Resident #107, surveyors twice observed visible hair on the resident’s chin, and the resident reported that staff had not offered to shave the chin. The resident had a diagnosis of other specified forms of tremors, moderate cognitive impairment (BIMS score of 09), and required substantial/maximal assistance with showering and personal hygiene. The care plan required staff assistance with bathing/showering and personal hygiene, and the ADL task list showed scheduled bath days and documented completion of a task to check for facial hair and shave as needed on several dates, again without staff initials. Progress notes did not show any refusal of shaving by the resident. A CNA stated she determined needed care by looking in the resident’s closet care plan, that CNAs were responsible for bathing/showering, and that staff checked for facial hair on shower days and should check daily. She acknowledged seeing facial hair that morning and intended to shave the resident later. The DON stated CNAs were responsible for checking and removing facial hair during showers and as needed, and that CNAs should not document facial hair removal when it had not been done.
Failure to Safely Manage Self-Administration of Inhalers and Medication Storage
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident approved for self-administration of medications could follow instructions so that medications were not left at the bedside. The resident had diagnoses including respiratory failure, heart failure, type 2 diabetes, and COPD, and was receiving oxygen via concentrator. Record review showed orders for a beta2-agonist inhaler and a corticosteroid inhaler, but no physician order for self-administration rights was initially found. The facility’s policy required that residents who self-administer be assessed by the IDT to ensure they could safely administer and store medications out of reach of other residents. On multiple observations, surveyors found the resident’s inhalers and lockbox not secured as required. During one observation, the resident was resting in bed with eyes closed, the oxygen concentrator running at two liters via nasal cannula, but the nasal cannula was not in place, and both the corticosteroid and beta2-agonist inhalers were left unsupervised on the over-bed table. The resident stated they had been told they could use their own inhalers. On a later observation, a lockbox with the key left in the lock was seen on the over-bed table, and the resident stated the lockbox contained prescription inhalers but could not recall when it was provided. On another observation, the lockbox with the key still in the lock remained on the over-bed table while the resident was resting with oxygen in place. Interviews with staff confirmed that the resident had been approved for self-administration but revealed gaps in adherence to policy and lack of staff familiarity with self-administration procedures. An LPN stated the resident had been approved to self-administer inhalers at the bedside unsupervised and acknowledged not being familiar with the self-administration policy, while also stating that medications should not be left unattended on the over-bed table and that the lockbox should not have the key in the lock. The DON described the process for approving self-administration, including assessment, demonstration of use, and locked storage, and stated it would not be appropriate to leave a key in the lock or medications out on the over-bed table. Another LPN reported there had not been prior residents with self-administration rights and agreed that medications should not be stored on the over-bed table or in a lockbox with the key in place. CNAs stated that any medications found on the over-bed table would be reported to a nurse and that residents were not allowed to have unstored medication out in the open in their rooms.
Failure to Complete Significant Change MDS After Hospice Election
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) MDS within 14 days of a resident’s hospice service election, as required by the CMS RAI Manual. The resident had a terminal prognosis related to Parkinson’s disease and a quarterly MDS dated 02/20/2026 showed severe cognitive impairment (BIMS score of 4) and no hospice services. The care plan, reviewed on 03/16/2026 and revised on 04/07/2025, was updated with an intervention initiated on 04/20/2026 indicating that a named hospice provider would supply a CNA up to five times weekly, an RN weekly and PRN, social services monthly and PRN, and chaplain services monthly and PRN, with a contact number listed. A CNA reported that the resident’s baths were being provided by hospice aides who visited about three days a week. Record review showed no physician’s order for hospice services in the electronic health record at the time of survey, and progress notes from 03/01/2026 through 04/24/2026 contained no hospice notes. During interview, the MDS Coordinator stated she completes all MDS assessments and had not done a significant change MDS for this resident’s hospice admission because there was no physician’s order in the system to alert her. Upon review, she identified that an order to admit the resident to hospice services was dated 03/24/2026 but was not entered into the system until 04/23/2026, and acknowledged that the ARD should have been set within 14 days of hospice election, by 04/07/2026. The DON stated that the nurse on duty when the resident was admitted to hospice should have entered an admission order for hospice and expressed that she believed nurses understood they were responsible for adding such orders, treating them like any other order.
Failure to Care Plan Communication Deficit for Nonverbal Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive, person-centered care plan addressing a communication deficit for a nonverbal resident. The resident had been admitted with diagnoses including nontraumatic intracerebral hemorrhage in the brain stem, major depressive disorder, and anxiety disorder, and was unable to move the right side of the body, including the face and mouth, due to a stroke. The admission MDS documented unclear speech, that the resident rarely or never made themself understood, sometimes understood others, and responded adequately only to simple, direct communication, while the BIMS score was 15, indicating intact cognition. The Baseline Care Plan noted the resident did not communicate easily with staff, but on review of the Comprehensive Care Plan initiated at admission, no communication deficit with corresponding interventions had been initiated. Record review showed multiple assessments and notes documenting the resident’s nonverbal status and alternative communication methods, but these findings were not translated into a specific communication care plan problem with individualized interventions. The Nursing Admit/Readmit/Quarterly Assessment described the resident as soft spoken and mouthing words, and progress notes indicated the resident was very soft spoken, nonverbal, able to shake the head yes and no, and utilized sign language. A social services admission assessment documented that the resident’s speech was clear, that the resident was nonverbal, used sign language as another mode of communication, and rarely or never was able to make themself understood but could understand others. An APRN note and an SLP evaluation further confirmed that the resident communicated by nodding or shaking the head and had impaired communication skills. Interviews with staff demonstrated that, in the absence of a care-planned communication deficit with defined interventions, staff relied on general approaches and did not have consistent tools or guidance for communicating with the resident. CNAs and an RNA reported communicating with the resident by asking yes/no questions, observing body language and facial cues, and noting that the resident used the left hand to indicate numbers or point to areas of pain, while also stating they did not know sign language and had not seen communication boards or other aids. An LPN reported talking to nonverbal residents as to verbal residents, using facial expressions to interpret needs, and was unaware of any communication boards or specific interventions for nonverbal residents. The MDS coordinator and DON acknowledged that a communication deficit should have been triggered and care planned at admission for a nonverbal resident, and the DON further stated the facility did not have policies for care plans, comprehensive care plans, communication, or communicating with nonverbal residents.
Failure to Use Required Gait Belt During Transfer Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to utilize appropriate transfer equipment, specifically a gait belt, during a toilet transfer for one resident, resulting in a fall and knee abrasion. The resident had medical diagnoses including a left lower leg blood clot, stage 4 kidney disease, type 2 diabetes, neuropathy, and was care planned as high risk for falls with gait and balance problems and limited mobility related to weakness. The resident was also non‑weight bearing on the left lower extremity and required assistance of two staff members with all transfers. The admission MDS showed the resident was cognitively intact and had a history of a fall in the prior months. Prior to the cited incident, the resident had experienced multiple falls at the facility. An unwitnessed incident report documented that the resident slid out of a wheelchair while trying to pick up a ring from the floor, with no injury. A later witnessed incident documented that the resident’s legs gave out during a transfer, and the resident was assisted to the floor without injury and then transferred back to the wheelchair using a gait belt and two staff. These events established that the resident had recurrent episodes of legs “giving out” and required two‑person assistance and a gait belt for safe transfers. On the date of the deficiency, during a transfer from wheelchair to toilet in the bathroom, two staff members (a MA‑C and a CNA) attempted to stand and pivot the resident using the right leg while the resident held onto grab bars, but they did not use a gait belt. The resident’s legs collapsed, and the resident went down to the knees, sustaining an abrasion to the right kneecap, which the resident attributed to the lack of a gait belt. Interviews with the resident, nursing staff, therapy staff, and administration confirmed that the resident was non‑weight bearing on the left leg, required two‑person assistance and a gait belt for transfers, and that facility expectations and policy required use of a gait belt for all assisted transfers. Staff involved acknowledged they “forgot” to use the gait belt during this transfer, and other staff confirmed that gait belts were expected to be used with every transfer when assistance was needed.
Failure to Maintain Active Oxygen Orders and Humidified Oxygen for Resident Comfort
Penalty
Summary
The deficiency involves the facility’s failure to ensure that oxygen therapy orders were properly scheduled and active before administration and to provide humidified oxygen in accordance with a resident’s preferences and comfort needs. Resident #125, who had diagnoses including respiratory failure, heart failure, and type II diabetes, had an active order entered on 04/15/2026 for oxygen at 2–4 liters via nasal cannula, but the order lacked a start date and did not appear as a scheduled order in the electronic record. The admission MDS in progress with an ARD of 04/20/2026 did not indicate that the resident was receiving oxygen therapy, despite documentation on the resident’s oxygen saturation summary that the resident was on oxygen on multiple dates in April. An LPN confirmed that the oxygen order had been present since 04/15/2026 but was not set up as a scheduled order and had no active date. The facility also failed to provide and maintain humidified water for the resident’s nasal comfort over several days. On multiple observations from 04/20/2026 through 04/22/2026, the resident’s humidifier bottle was found undated or dated but empty, while the resident was receiving 2 liters of oxygen via nasal cannula. The resident repeatedly reported that their nose was very dry and that the humidifier bottle had been empty since Monday, and stated they had asked staff to change the water bottle but could not identify to whom. An LPN acknowledged that the humidified water bottle dated 04/21/2026 was empty and stated it should not have been empty at 2 liters of oxygen, suspecting that someone may have dated an empty bottle without actually changing it. The administrator and DON stated their expectation that humidified water bottles be changed on Tuesday evenings with the tubing or when empty, but there was no facility policy addressing oxygen tubing, storage, or humidified water bottles, and the existing oxygen safety policy only addressed handling oxygen, not equipment.
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