Monette Manor, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Monette, Arkansas.
- Location
- 669 Hwy 139 North, Monette, Arkansas 72447
- CMS Provider Number
- 045477
- Inspections on file
- 6
- Latest survey
- December 31, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Monette Manor, Llc during CMS and state inspections, most recent first.
The facility did not update care plans with specific fall interventions after several residents experienced falls, despite their complex medical conditions and histories of falls. Staff interviews confirmed that the process for care plan updates was not followed, and the responsibility for these updates was not fulfilled. The facility's care plan policy was requested but not provided.
The facility failed to report and investigate three incidents of resident-to-resident abuse and an unwitnessed fall with serious injury. In one case, a resident with dementia was aggressive towards another, but the administrator did not report it due to the brief duration and lack of injuries. Another resident fell from a wheelchair, resulting in a hip fracture, but the incident was not reported as it was reviewed via video. In the third case, a resident was attacked by a roommate, but the administrator did not report it, considering it a minor altercation.
The facility failed to transmit MDS assessments to CMS within the required 14-day timeframe for several residents. The assessments were either not accepted or still export-ready, contrary to the facility's policy requiring transmission within 31 days of completion. This affected residents with admission and significant change assessments.
The facility failed to implement comprehensive care plans for residents, leading to deficiencies in addressing medical and behavioral needs. A resident with multiple diagnoses lacked a baseline care plan, while another's pain management was not reflected in their care plan. A resident with aggressive behaviors had inadequate interventions, and two residents had missing interventions for catheter care and wound management. The DON acknowledged these omissions, highlighting the need for timely updates.
The facility failed to complete timely clinical assessments for six residents, impacting their quality of care. Overdue assessments included wandering risk, side rail, fall scales, and pain interviews. Interviews revealed confusion and lack of responsibility among staff, with the DON and Social Director unclear on who should complete these assessments.
The facility did not follow the prescribed menu for pureed diets during a lunch service. A dietary aide forgot to puree white beans, resulting in residents not receiving them as part of their meal. The Assistant Dietary Manager confirmed the omission, and the DON highlighted the importance of adhering to menus for residents with specific dietary needs. The facility also lacked a policy for menus.
The facility failed to follow infection control procedures, as observed when CNAs did not perform hand hygiene between assisting two residents at the dining table. Additionally, proper infection control was not maintained during perineal and catheter care for a resident with chronic kidney disease, a PEG tube, and a suprapubic catheter. CNAs and the DON did not use personal protective equipment as required, and perineal care was performed incorrectly, leading to debris around the catheter insertion site and red open areas.
A facility failed to complete a baseline care plan within 48 hours for a resident with multiple diagnoses, including congestive heart failure and chronic kidney disease. The DON confirmed that no admission assessment or care plan was initiated, despite the facility's policy requiring these actions.
The facility's administration failed to report incidents to the SSA, including resident-to-resident altercations and an unwitnessed fall with major injury. The administrator, responsible for ensuring compliance with regulations, did not report these incidents, as confirmed during an interview.
The facility lacked an effective governing body, leading to issues in Quality Assurance and Performance Improvement Plan (QAPI) feedback systems, care plan implementation, and MDS timing and transmission. The absence of an MDS Coordinator since mid-August resulted in widespread deficiencies, with the ADON temporarily handling these duties alongside other responsibilities. The Administrator acknowledged the need to improve the feedback system and shift QAPI focus to resident concerns.
The facility failed to employ a qualified MDS Coordinator, leaving the DON, who lacked MDS training, to handle these duties with limited support from an unavailable MDS Consultant. The ADON was overwhelmed with multiple responsibilities, including admissions and infection prevention, leading to non-compliance with state regulations.
The facility's QAPI program failed to effectively address resident concerns, focusing instead on admissions and operational issues. Critical issues like falls, behaviors, and care plans were not discussed, and the Administrator acknowledged the feedback system's ineffectiveness.
Failure to Update Care Plans with Fall Interventions After Resident Falls
Penalty
Summary
The facility failed to ensure that fall interventions were incorporated into person-centered care plans following falls for five out of seven residents reviewed. Each of these residents experienced a fall during a specified period, but their care plans were not updated to reflect new or revised interventions addressing the specific incidents. The absence of these interventions was confirmed through record reviews, care plan audits, and interviews with facility staff, including the RN Supervisor, Restorative CNA, DON, and Administrator. The residents involved had significant medical histories and varying degrees of cognitive and physical impairment. For example, one resident had severe cognitive impairment and multiple fractures, another had muscle wasting and hemiplegia following a stroke, and others had diagnoses such as congestive heart failure, encephalopathy, and gait abnormalities. Despite these complex needs and documented falls, their care plans did not include interventions specific to the falls that occurred during the review period. Interviews with facility staff revealed a lack of clarity and follow-through regarding the process for updating care plans after a fall. The RN Supervisor, who also served as the MDS Coordinator, acknowledged that fall interventions were not added to the care plans for the incidents in question. The DON and Administrator both confirmed that the responsibility for updating care plans with fall interventions rested with the MDS Coordinator, and that this had not been done for the affected residents. The facility's policy and procedure for care plans was requested but not provided during the survey.
Failure to Report and Investigate Incidents
Penalty
Summary
The facility failed to report three incidents of resident-to-resident abuse and an unwitnessed fall with serious injury, as well as failed to conduct thorough investigations of these incidents. In the first case, a resident with severe dementia and behavioral disturbances was aggressive towards another resident in the dining room. Despite the incident being captured on video and witnessed by staff, the administrator did not report it to the State Office of Long-Term Care, citing the brief duration and lack of injuries. In the second incident, a resident with severe cognitive impairment fell from a wheelchair, resulting in a hip fracture that required surgical repair. The fall was unwitnessed, and although the staff responded quickly, the administrator did not report it, considering the video review as sufficient. No witness statements or investigation documentation were available, and the video was not accessible due to the time elapsed since the incident. The third incident involved a resident with intact cognition who was physically attacked by a roommate. The resident recorded the altercation and showed it to staff, who intervened and moved the resident to a different room. Despite the evidence and reported injuries, the administrator did not report the incident, believing it to be a minor altercation. No incident reports or investigation documentation were provided, and the facility failed to document the injuries reported by the resident and staff.
Failure to Transmit MDS Assessments Timely
Penalty
Summary
The facility failed to electronically transmit encoded, accurate, and complete Minimum Data Set (MDS) assessments to the Centers for Medicare and Medicaid Services (CMS) within the required time frame of 14 days. This deficiency affected six residents whose MDS assessments were reviewed. Specifically, the assessments for these residents were either not accepted or were still export-ready, indicating a failure in the transmission process. The facility's policy, revised in December 2002, requires comprehensive assessments to be transmitted electronically within 31 days of the MDS completion date, but this was not adhered to for the residents in question. The residents involved had various types of assessments, including admission and significant change assessments, with Assessment Reference Dates (ARDs) ranging from November 2023 to March 2024.
Deficiencies in Care Plan Implementation and Updates
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for several residents, leading to deficiencies in addressing their medical and behavioral needs. Resident #120 was admitted with multiple diagnoses, including congestive heart failure and chronic kidney disease, but lacked a baseline care plan and admission assessment. This oversight resulted in the absence of documented interventions for cognitive function, fall risk, and medication management, including oxygen and anxiety medication. The Director of Nursing acknowledged the missing care plan and the need for correction. Resident #220, diagnosed with osteoarthritis and kidney disease, had orders for pain medication that were not reflected in the care plan. Similarly, Resident #37, with a diagnosis of altered mental status, exhibited aggressive behaviors and wandering tendencies that were not adequately addressed in the care plan. Despite multiple incidents of physical altercations with staff and complaints from other residents, the care plan lacked interventions for monitoring and managing these behaviors. The facility's failure to update the care plan as the resident's needs changed potentially put other residents at risk. Residents #13 and #14 also experienced deficiencies in their care plans. Resident #13, with a suprapubic catheter, did not have interventions for catheter care or enhanced barrier precautions documented. Resident #14, with diagnoses including congestive heart failure and blood clots, lacked interventions for anticoagulant use and wound care in the care plan. The Director of Nursing confirmed these omissions, highlighting the facility's failure to implement necessary interventions and update care plans in a timely manner.
Failure to Complete Timely Clinical Assessments
Penalty
Summary
The facility failed to complete necessary clinical assessments for six residents, which affected their quality of care. The overdue assessments included wandering risk assessments, side rail assessments, fall scales, pain interviews, neurological checklists, skin observation tools, and skilled charting. These assessments were crucial for accurately portraying the residents' care in the Minimum Data Set (MDS) and implementing care plan interventions. The lack of timely assessments indicates a significant oversight in maintaining up-to-date and comprehensive care plans for the residents. Interviews with the Director of Nursing (DON) and the Social Director revealed a lack of clarity and responsibility regarding the completion of these assessments. The DON, who was also handling Infection Preventionist duties and assisting with MDS tasks, admitted to not being fully familiar with the MDS process. The MDS nurse had left, and the DON was temporarily responsible for certain sections of the MDS, while the Social Director was responsible for others. However, there was confusion about who was responsible for the overdue assessments, leading to a gap in the residents' care documentation.
Failure to Follow Pureed Diet Menu
Penalty
Summary
The facility failed to adhere to the prescribed menu for pureed diets during a lunch service, as observed on 09/26/2024. Dietary Aide #2 was overheard stating that they did not puree white beans, which were part of the menu for residents requiring pureed diets. During the lunch service, residents received pureed pork chop, turnip greens, cornbread, and banana creme pie, but the pureed white beans were not served. The Assistant Dietary Manager confirmed that the menu should have included pureed white beans and acknowledged that the omission was due to Dietary Aide #2 forgetting to puree them. The Director of Nursing emphasized the importance of following menus, especially for residents with specific dietary needs such as those with swallowing issues or diabetes. It was also noted that the facility lacked a policy for menus.
Infection Control Lapses in Resident Care
Penalty
Summary
The facility failed to adhere to infection control procedures, as observed during a survey. Two CNAs did not perform hand hygiene between assisting two residents at the assisted dining table, potentially spreading infection. Additionally, the facility did not follow proper infection control procedures during perineal and catheter care for a resident with chronic kidney disease, a PEG tube, and a suprapubic catheter. The CNAs and the DON did not use personal protective equipment as required for Enhanced Barrier Precautions, and perineal care was performed incorrectly, leading to debris around the catheter insertion site and red open areas in the perineal region. The resident involved was cognitively intact and had informed staff about the condition of the open areas, which had been present for a couple of days. The facility's training materials and policies clearly outlined the correct procedures for catheter and perineal care, as well as the use of gowns and gloves during high-contact care activities. However, these procedures were not followed, as confirmed by interviews with the CNAs and the DON, who acknowledged the lapses in protocol.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to complete a baseline care plan with the minimum necessary information within 48 hours after the admission of a resident, which is required to promote continuity of care. The resident, who was admitted within the last 30 days, had diagnoses including congestive heart failure, atrial fibrillation, chronic kidney disease, and repeated falls. A review of the resident's electronic records revealed that there was no admission assessment or care plan initiated on the date of admission. During an interview, the Director of Nursing (DON) confirmed that the nurses are responsible for completing assessments upon admission or readmission, and she is responsible for the baseline care plan within 4 hours of admission. However, she acknowledged that no admission assessment or care plan had been completed for the resident.
Failure to Report Incidents to SSA
Penalty
Summary
The facility's administration failed to ensure the administrator was knowledgeable regarding reporting requirements, leading to the failure to immediately report certain incidents to the State Survey Agency (SSA). Specifically, a resident-to-resident altercation involving Resident #71 on January 14, 2024, an unwitnessed fall with major injury involving Resident #48 on July 10, 2024, and another resident-to-resident altercation involving Resident #46 on August 16, 2024, were not reported to the SSA. The administrator acknowledged during an interview that they were responsible for reporting such incidents, as outlined in the job description provided by the Business Office Manager, which includes ensuring compliance with all local, state, and federal regulations.
Deficiency in Governing Body and MDS Coordination
Penalty
Summary
The facility failed to maintain an effective governing body to ensure proper management and operation, particularly in the areas of Quality Assurance and Performance Improvement Plan (QAPI) feedback systems, care plan implementation, and the timing and transmission of Minimum Data Sets (MDS). The survey team found that there was no MDS Coordinator in place since the previous coordinator left on 08/14/2024, leading to widespread issues with MDS timing and care plan implementation. The Assistant Director of Nursing (ADON) was temporarily assigned these duties, along with other responsibilities such as admissions, infection prevention, and assessments, which may have contributed to the deficiencies. Interviews with the Administrator revealed that the current feedback system was ineffective, as evidenced by the concerns brought to his attention. The Administrator acknowledged the need to shift the focus of the QAPI from admissions to more resident concerns. The governing body, as described by the Director of Nursing (DON), involves an interdisciplinary team including the administrator, business office manager, medical director, and therapy. However, the facility's policy states that the governing body is responsible for the QAPI program, and the Administrator is accountable to the governing body. The lack of a dedicated MDS Coordinator and the ineffective feedback system indicate a failure in the governing body's responsibilities.
Facility Lacks Qualified MDS Coordinator
Penalty
Summary
The facility failed to ensure that qualified staff were employed to accurately encode, transmit, and implement assessments and care plans. The Minimum Data Set (MDS) Coordinator position, responsible for completing all MDS and Care Area Assessments (CAAs), scheduling and leading Care Plan Conferences, and transmitting completed MDS assessments to the state, was vacant after the previous coordinator left on 08/14/2024. The Director of Nursing (DON), who lacked training in MDS, was temporarily assigned these duties with assistance from an MDS Consultant. However, the consultant was not available for interviews, and the DON admitted to not being familiar with the MDS process. The Administrator acknowledged that the workload assigned to the Assistant Director of Nursing (ADON), who was also handling admissions, infection prevention, assessments, and other duties, was unrealistic for long-term success. The facility was in the process of hiring new staff to fill the DON and MDS positions, but at the time of the survey, the ADON was overwhelmed with responsibilities, and the facility was not in compliance with state regulations requiring qualified staff for MDS tasks.
Ineffective Feedback System in QAPI
Penalty
Summary
The facility failed to ensure an effective feedback system was in place for its Quality Assurance and Performance Improvement Plan (QAPI). A review of the Quarterly QAPI Minutes indicated that discussions were held on admissions, staffing issues, facility issues, ongoing staff education, shower scheduling, improving transport, and staff scheduling. However, there was no mention of critical resident concerns such as falls, behaviors, Minimum Data Sets (MDS), or care plans, which were identified during the survey. This omission suggests a lack of comprehensive review and discussion of all pertinent issues affecting resident care and safety. During an interview, the Administrator acknowledged that issues are typically brought to their attention through observation, staff, family, or resident concerns. The Administrator admitted that the current feedback system is ineffective, as evidenced by the concerns raised that week. The Administrator also noted that the facility had been focused on admissions in their QAPI efforts over the past year, neglecting to address resident concerns adequately. This lack of focus on resident issues, such as behaviors or abuse/neglect, during QAPI meetings contributed to the deficiency identified by the surveyors.
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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