Ouachita Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Camden, Arkansas.
- Location
- 1411 Country Club Road, Camden, Arkansas 71701
- CMS Provider Number
- 045207
- Inspections on file
- 27
- Latest survey
- August 21, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Ouachita Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that expired food items, such as buttermilk and bread, were not promptly removed from storage, and opened bags of hamburger buns were left unsealed, exposing them to contamination. Ice scoop holders were dirty, and dietary staff failed to follow hand hygiene protocols, handling clean equipment and food items after touching dirty surfaces without washing their hands. These deficiencies were confirmed through staff interviews and direct observation.
A cognitively impaired resident with a history of sexual behaviors engaged in a sexual act with a staff member, which was witnessed by another staff and reported to administration and law enforcement. Despite ongoing reports of the resident's inappropriate sexual behaviors, the facility did not implement adequate supervision or interventions, and the abuse policy lacked specific guidance on sexual abuse prevention. The resident's care plan and assessments failed to accurately document these behaviors or address the risk, contributing to the incident.
A resident with moderate to severe cognitive impairment and a history of inappropriate sexual behaviors did not have these behaviors identified or addressed in their care plan. Despite multiple incidents involving public sexual acts and sexual contact with staff and other residents, the care plan lacked goals, interventions, or assessments for consent, and there were no physician orders for safe sex education or competency evaluation. Staff were aware of the behaviors but did not implement formal interventions or update the care plan until after a significant incident occurred.
A resident with Alzheimer's and moderate dementia did not consistently receive care plan interventions, including the use of AFO braces and protective sleeves, leading to skin integrity issues. CNAs were unaware of some care requirements, and the facility lacked a policy on care plans.
The facility failed to ensure proper hand hygiene and glove usage among dietary staff, leading to potential cross-contamination. Additionally, the facility did not maintain proper food storage and quality standards, with dented cans, discolored lettuce, and improperly stored leftovers observed. The physical environment of the kitchen and dishwashing areas was also not maintained in a clean and sanitary condition, with residue, stains, and chipped surfaces noted.
The facility failed to prevent the misappropriation of narcotics for two residents, leading to discrepancies in medication counts and inadequate pain management. An LPN admitted to not signing out medications immediately and incorrectly documenting administration times. The DON was notified but did not know how to handle the situation. One resident reported significant pain but did not receive medication.
The facility failed to follow the planned menu for resident meals, resulting in residents on pureed diets not receiving pureed Spanish rice and residents on mechanical soft diets not receiving tortilla bread. The dietary employee admitted to overlooking these items.
The facility failed to ensure that pureed food items were blended to a smooth, lump-free consistency, affecting five residents on pureed diets. Observations revealed that pureed beef enchilada, vegetable blends, flour tortillas, and sausage were not prepared correctly, posing a risk of choking or other complications.
The facility failed to ensure proper hand hygiene and glove changes during perineal care for two residents, potentially affecting seven residents. Additionally, housekeeping staff did not perform hand hygiene during clean laundry delivery. The facility also failed to adhere to droplet precautions for residents with COVID-19, affecting all 78 residents.
The facility failed to ensure privacy and dignity for a resident during daily care activities. CNAs did not close the window shade or the room door, exposing the resident. Staff interviews confirmed that privacy protocols were not followed.
A resident's personal and medical information was left exposed on an unlocked medication cart and computer, compromising their privacy. The incident was confirmed by both the LPN and the nursing administration, highlighting a failure to adhere to the facility's confidentiality policies.
A facility failed to ensure a bathroom sink in a resident's room was properly attached to the wall, leading to a potential hazard. The Maintenance Director confirmed the sink was loose due to residents using it to push themselves up, and acknowledged that the screws were coming loose. The issue was later addressed and fixed.
The facility failed to complete the PASRR Level 1 pre-screening for a resident with bipolar II disorder before admission. The screening was delayed until well after the resident's admission date. The ADON confirmed the delay and noted the absence of a policy for MDS or PASRR.
The facility failed to provide perineal care in accordance with professional standards for two residents with severe cognitive impairment. CNAs did not follow proper hygiene practices, including changing gloves and sanitizing hands, and used inadequate wiping techniques. This non-compliance with established protocols highlights significant lapses in the quality of care.
The facility failed to follow manufacturer guidance during the transfer of a resident using a sit-to-stand lift, resulting in unsafe practices. The resident, who has severe cognitive impairment, was transferred without the required buttock strap, and their left hand was forcibly placed on the handle. This deficiency has the potential to affect other residents requiring similar transfers.
The facility failed to ensure a resident's peg tube was flushed with the prescribed 60 cc of water before and after medication administration, instead using only 30 cc. This discrepancy was confirmed by an LPN and the ADON, who acknowledged the potential complications of not following the physician's orders.
The facility failed to ensure medications were stored and labeled correctly, with instances of medications left in residents' rooms, incorrect self-administration of nasal spray by a resident, and medication carts left unlocked and unattended by LPNs.
Deficient Food Storage, Expired Items, and Hand Hygiene in Dietary Services
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food storage, preparation, and handling practices. Expired food items, including a half-gallon of buttermilk and three bags of bread, were found in storage past their expiration dates, despite the Dietary Manager's routine checks. Additionally, several opened bags of hamburger buns were left unsealed, exposing them to environmental contaminants and potential pests. Ice scoop holders attached to ice chests were found to be dirty, with residue at the bottom, and the scoops were resting directly on the unclean surfaces. Staff interviews confirmed that cleaning responsibilities for these items were not consistently followed. Dietary staff were also observed failing to adhere to proper hand hygiene protocols. One dietary aide turned off a faucet with bare hands and then handled clean glasses without washing hands. Another aide handled milk cartons, shakes, and condiments, then picked up cups and glasses by the rims without washing hands after touching potentially dirty objects. A third staff member touched a blender motor and then handled clean equipment without washing hands. These actions were in direct violation of the facility's hand washing policy, which requires hand hygiene after contact with dirty equipment or surfaces and before handling clean items.
Failure to Protect Cognitively Impaired Resident from Sexual Abuse by Staff
Penalty
Summary
A cognitively impaired resident with a history of stroke, moderate dementia, and mood disorders was involved in a sexual act with a staff member, specifically a housekeeper, within the facility. The incident was witnessed by a CNA, who observed the resident performing oral sex on the housekeeper in the resident's bathroom. The event was reported to the facility administrator and local law enforcement, and the housekeeper was immediately terminated. The resident had a documented history of sexual behaviors with other residents and staff, as reported by multiple employees, but these behaviors were not consistently identified or addressed in the resident's Minimum Data Set (MDS) assessments or care plan documentation. Despite the resident's ongoing sexually inappropriate behaviors, the facility failed to implement adequate interventions or supervision to prevent such incidents. Staff interviews revealed that the resident was known for groping and attempting sexual contact with both staff and other residents, yet there were no specific measures in place to restrict unsupervised access to the resident by male staff or to ensure staff were not alone with the resident. The facility's abuse and neglect policy did not specifically address sexual abuse, nor did it provide clear guidance or training for staff on recognizing, preventing, or intervening in cases of sexual abuse involving residents. The facility's documentation and care planning did not accurately reflect the resident's sexual behaviors or risk for abuse, and there was a lack of physician orders or assessments regarding the resident's capacity to consent to sexual activity. Interviews with facility leadership and clinical staff indicated uncertainty about how to assess sexual consent capacity and how to manage residents with hypersexual behaviors. The failure to identify, document, and address the resident's risk for sexual abuse, combined with insufficient staff training and supervision, directly contributed to the occurrence of sexual activity between the resident and a staff member.
Failure to Address and Care Plan Resident Sexual Behaviors
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan that addressed a resident's sexual behaviors, resulting in the absence of goals, interventions, or plans for safe sexual activity, assessment of competency for consent, redirection from other residents, and protection from unethical staff. Despite multiple documented incidents of inappropriate sexual behaviors, including public sexual acts and sexual contact with both staff and other residents, the care plan did not reflect these behaviors or provide specific interventions to address them. The care plan only noted the resident as sexually active and included general statements about respecting privacy during sexual activity with consenting partners, without addressing the resident's cognitive impairment or the need for consent assessment. The resident in question had a history of stroke, hemiplegia, moderate dementia, major depressive disorder, mood disorder, and anxiety disorder, with consistently low BIMS scores indicating severe to moderate cognitive impairment. Multiple MDS assessments failed to identify any sexual behaviors, despite staff and witness reports of ongoing inappropriate sexual conduct. Staff interviews and documentation revealed that the resident engaged in repeated sexual behaviors, including grabbing and touching staff and other residents, and was involved in an incident of oral sex with an employee. However, there were no physician orders for safe sex education, STD screening, or competency evaluation for sexual consent. Interviews with staff, including the DON, Administrator, and APRNs, confirmed that the resident's sexual behaviors were known and discussed, but no formal interventions or care plan updates were made to address these behaviors until after a significant incident occurred. Staff relied on informal redirection and discussions with the resident's representative, but there was no policy or procedure in place to manage such behaviors, nor were there documented interventions to prevent further incidents or protect the resident and others from harm.
Failure to Implement Care Plan Interventions
Penalty
Summary
The facility failed to consistently implement care plan interventions for a resident diagnosed with Alzheimer's disease and moderate dementia with agitation. The resident was severely cognitively impaired and required assistance with personal hygiene. The care plan indicated the resident was non-weight bearing due to dementia and required bilateral AFOs for foot drop when out of bed, as well as protective sleeves to prevent impaired skin integrity. However, observations revealed that the resident was not wearing the protective sleeves or AFO braces on multiple occasions, leading to broken skin areas with dried blood on the resident's arm. Interviews with CNAs confirmed that the care plan was the primary source of information for resident care, yet there was a lack of awareness regarding the requirement for AFO braces. The facility did not have a policy or procedure on care plans, as confirmed by the Administrator. The Assistant Director of Nursing acknowledged the presence of AFO braces in the resident's room and confirmed their necessity as per the care plan. This lack of consistent implementation of the care plan interventions contributed to the deficiency identified by the surveyors.
Improper Hand Hygiene and Food Storage Practices
Penalty
Summary
The facility failed to ensure proper hand hygiene and glove usage among dietary staff, leading to potential cross-contamination. Observations revealed that dietary employees handled clean dishes and food items without washing their hands after touching dirty objects. For instance, one dietary employee touched a dirty coffee cup and a clipboard, then handled clean glasses and plates without washing her hands. Another dietary employee used a water hose to clean plates and then handled clean plates without washing his hands. Additionally, a dietary employee contaminated her gloves by touching a spray bottle and then handled tortillas without changing gloves or washing her hands. A CNA also failed to sanitize her hands before handling food tray covers, touching the inside of the covers with her fingers and thumbs, which was confirmed by an RN as improper practice. The facility also failed to maintain proper food storage and quality standards. Dented cans of pumpkin and peach pie filling were found on a rack with non-dented cans. In the walk-in refrigerator, leftover sausage, scrambled eggs, and bacon were stored in plastic bags for use the next day, and discolored shredded lettuce was observed. In the walk-in freezer, an opened box of beef patties was not covered or sealed. An opened bottle of lemon juice was stored in the storage room instead of being refrigerated as per the manufacturer's specifications. The physical environment of the kitchen and dishwashing areas was not maintained in a clean and sanitary condition. Observations included gray/black residue on the ceiling/wall above a metal rack, rotted and chipped door frames, missing baseboards with accumulated residue, brown stains on the ceiling air conditioning cover, peeling paint exposing cement, rust and black stains around the 3-compartment sink, oven, and fluorescent lights, and chipped floors with black stains. The storage room had black residue in the corners where the wall and ceiling meet, which was described by the Dietary Supervisor as looking like mildew.
Misappropriation of Narcotics and Inadequate Pain Management
Penalty
Summary
The facility failed to prevent the misappropriation of narcotics for two residents, leading to discrepancies in the controlled medication count and potential complications in pain management. On 05/14/2024, the surveyor observed that the controlled medication on hand did not match what was documented in the narcotic book for two residents. Specifically, there were discrepancies in the counts of Pregabalin, Oxycodone, and Hydromorphone. An LPN admitted to not signing out the medications immediately after administration and incorrectly documenting the administration times. The LPN also altered the administration time after being informed of the discrepancies by the surveyor. The Director of Nursing (DON) was notified of the discrepancies but admitted to not knowing how to handle the situation. Additionally, one of the residents reported not receiving any pain medication despite experiencing significant pain during therapy. The therapist confirmed that the resident had reported pain but did not inform the nurse, as she did not believe the pain was severe. This series of actions and inactions led to the misappropriation of narcotics and inadequate pain management for the residents involved.
Failure to Follow Planned Menu for Resident Meals
Penalty
Summary
The facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents. During the noon meal service, residents who required pureed diets were not served pureed Spanish rice as specified on the menu, and no substitutes were provided. Additionally, residents on mechanical soft diets did not receive the tortilla bread that was listed on the menu. The dietary employee admitted to overlooking these items, resulting in the deficiency observed by the surveyor.
Failure to Ensure Proper Consistency of Pureed Food
Penalty
Summary
The facility failed to ensure that pureed food items were blended to a smooth, lump-free consistency, which is necessary to minimize the risk of choking or other complications for residents requiring pureed diets. During observations on 05/13/2024, Dietary Employee (DE) #3 prepared pureed beef enchilada, vegetable blends, and flour tortillas, all of which were found to have inappropriate consistencies. The pureed beef enchilada was gritty, the vegetable blend did not form properly, and the flour tortilla was thick, sticky, and lumpy. Both DE #3 and a certified nursing assistant confirmed these observations when questioned by the surveyor. On 05/14/2024, the pureed sausage served for breakfast was also found to be lumpy and not smooth. This was confirmed by a certified nursing assistant and the Director of Nursing, who noted that the consistency was more like mechanical rather than pureed. The kitchen was asked to prepare another batch of pureed sausage, which was then compared to the initial serving. DE #3 acknowledged that the initial pureed sausage was not smooth. These deficiencies had the potential to affect five residents who were on pureed diets.
Failure to Ensure Proper Hand Hygiene and Droplet Precautions
Penalty
Summary
The facility failed to ensure proper hand hygiene and glove changes during perineal care for two residents. Observations revealed that CNAs did not perform hand hygiene upon entering the residents' rooms or before starting care. Additionally, gloves were not changed during the perineal care process, and hand hygiene was not performed between glove changes. This failure was observed during the care of two residents who required assistance with perineal care, potentially affecting seven residents in total. The CNAs also failed to provide adequate privacy by not closing window shades before exposing the residents during care. The facility's policy on hand hygiene and perineal care was not followed, as confirmed by interviews with the CNAs and the Director of Nursing (DON). The facility also failed to ensure proper hand hygiene during clean laundry delivery. Housekeeping staff did not perform hand hygiene before entering or after exiting residents' rooms while delivering clean laundry. The housekeeping staff was not adequately trained on the importance of hand hygiene, as evidenced by the absence of their signatures on the inservice education reports. The DON confirmed that there was no specific hand hygiene policy for laundry handling, and the housekeeping staff was not instructed to sanitize their hands before entering rooms. Additionally, the facility failed to adhere to droplet precautions for residents with COVID-19. Residents on droplet precautions were observed with their doors open, and some residents were seen without masks while outside their rooms. Staff, including the maintenance man, did not consistently wear personal protective equipment (PPE) when entering rooms with droplet precaution signs. The Infection Preventionist and RN confirmed that residents with COVID-19 should remain in their rooms with the doors closed to prevent the spread of the virus. The facility's failure to follow droplet precautions affected all 78 residents in the building.
Failure to Ensure Resident Privacy and Dignity
Penalty
Summary
The facility failed to ensure privacy and dignity for Resident #14 during activities of daily living care. On 05/13/2024, CNAs #3 and #4 entered Resident #14's room to perform a brief change and peri-care. During the procedure, CNA #3 removed the resident's brief while the window shade was open, exposing the resident's abdomen, private area, and legs. CNA #4, who was standing in front of the window, looked out twice before closing the shade. Additionally, the room door was left open during the resident's transfer from the bed to a wheelchair, and CNA #8 entered without knocking, further compromising the resident's privacy. Interviews with the staff, including CNAs #3, #4, and #8, as well as the Director of Nursing (DON) and the Administrator, confirmed that privacy protocols were not followed. CNA #4 acknowledged that the window shade should have been closed before removing the brief, and CNA #3 admitted that privacy should have been provided prior to care. The DON and the Administrator both emphasized the importance of maintaining privacy and dignity during resident care, including knocking and announcing before entering a resident's room.
Failure to Protect Resident's Confidential Information
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of Resident #178's personal and medical information. Resident #178, who had a diagnosis of Depression and Cerebral Infarction, was cognitively intact as per the Quarterly Minimum Data Set (MDS) assessment. On 05/15/24, a surveyor observed that the medication cart in the hallway outside Resident #178's room was left unlocked with the keys in the lock. Additionally, the laptop on the cart was open and displayed the resident's Electronic Medication Administration Record (E-MAR) profile, which included personal and medical information. This information was left unattended and accessible to unauthorized individuals. LPN #3 confirmed the medication and computer were left unattended and unlocked, exposing the resident's confidential information. On 05/16/24, both the Director of Nursing and the Assistant Director of Nursing confirmed that unauthorized individuals could view sensitive resident information if the computer screen was left unlocked. The facility's policy on confidentiality, which was presented to the surveyor, emphasized the importance of protecting residents' personal and medical records. An in-service training on HIPAA compliance highlighted that leaving resident information visible and unattended was a violation. Despite these policies, the incident demonstrated a failure to comply with the facility's confidentiality standards, thereby compromising Resident #178's privacy.
Improperly Attached Sink in Resident's Bathroom
Penalty
Summary
The facility failed to ensure a bathroom sink in room [ROOM NUMBER] was properly attached to the wall, which had the potential to affect one resident who had access to the room. During an observation, the sink was found not flush with the wall, with caulking material spread in globs and an open gap behind the cold-water knob. The Maintenance Director confirmed that the sink was loose due to residents using it to push themselves up, and acknowledged that the screws holding the sink were coming loose, which could potentially cause the sink to fall. Subsequent observations showed that the sink was later fixed, with no movement or gaps present. The Administrator stated that there is a preventative maintenance program in place, and the Maintenance Director rounds the facility daily to address maintenance issues. The Maintenance Director confirmed that urgent needs are addressed immediately, while basic needs are handled as time allows. The Maintenance Director also acknowledged that the issue with the sink in room [ROOM NUMBER] was addressed right away after being identified.
Failure to Complete PASRR Level 1 Pre-Screening Prior to Admission
Penalty
Summary
The facility failed to ensure a referral for Pre-Admission Screening and Resident Review (PASRR) was made for a resident reviewed for PASARR. Specifically, the facility did not complete the PASRR Level 1 pre-screening for a resident with bipolar II disorder prior to admission. The resident was admitted on 03/30/2024, and the PASRR Level 1 screening was only completed on 05/14/2024, well after the admission date. The resident's Care Plan, revised on 04/10/2024, indicated the presence of bipolar disorder and depression, with interventions in place for managing these conditions. During interviews, the Assistant Director of Nursing (ADON) confirmed that she was responsible for PASRR screenings since starting at the facility on April 12, 2024. The ADON acknowledged that PASRR Level 1 screenings should be completed before admission and confirmed that the screening for the resident in question was delayed until 05/14/2024. Additionally, the ADON stated that the facility did not have a policy for Minimum Data Set (MDS) or PASRR, indicating a lack of procedural guidelines for these critical assessments.
Deficient Perineal Care and Hygiene Practices
Penalty
Summary
The facility failed to provide perineal care in accordance with professional standards of care for two residents, leading to deficiencies in hygiene and infection control. Resident #14, who had severe cognitive impairment and was dependent on staff for toileting hygiene, was observed receiving inadequate perineal care. Certified Nursing Assistants (CNAs) #3 and #4 used only one wipe to clean the resident's private area and buttocks, did not change gloves or sanitize hands during the process, and were unsure if the resident was circumcised. This improper technique and lack of hygiene could potentially affect other residents requiring similar care in the same hall. Resident #52, also with severe cognitive impairment and dependent on staff for toileting hygiene, experienced similar deficiencies. During the perineal care process, CNA #3 did not perform hand hygiene, used inadequate wiping techniques, and failed to change gloves. Additionally, the resident was transferred using a lift with improper technique, causing discomfort and potential risk of injury. The CNAs did not follow the facility's peri-care procedure, which includes specific steps for cleaning, glove changes, and hand hygiene. The facility's policies and procedures for perineal care and hand hygiene were not adhered to by the CNAs, despite having been trained and evaluated on these procedures. The facility's in-service education reports indicated that the CNAs had received training on the importance of good hand hygiene and the proper use of hand sanitizers, yet these practices were not followed during the observed care. This failure to comply with established protocols highlights significant lapses in the quality of care provided to the residents.
Improper Use of Sit-to-Stand Lift During Resident Transfer
Penalty
Summary
The facility failed to follow manufacturer guidance during the transfer of a resident using a sit-to-stand lift. Resident #14, who has severe cognitive impairment and is dependent on staff for activities of daily living, was transferred from a wheelchair to a bed and back without using the required buttock strap. The resident's left hand, which cannot fully open, was forcibly placed on the handle by a CNA, and the resident's body was not properly supported during the transfer. This method of transfer was observed to be unsafe and not in compliance with the manufacturer's instructions, which mandate the use of a buttock strap for safety and comfort. The Director of Nursing and Assistant Director of Nursing both acknowledged that staff should follow manufacturer safety guidelines when operating the lift. Despite this, the CNAs involved did not adhere to these guidelines, putting the resident at risk. The facility's training checklist for the lift was also found to be non-specific, potentially contributing to the improper use of the equipment. This deficiency has the potential to affect other residents who require similar transfers using the sit-to-stand lift.
Failure to Follow Physician Orders for Peg Tube Flushes
Penalty
Summary
The facility failed to ensure that a resident's peg tube was flushed with the appropriate amount of water as ordered by the physician. Specifically, the physician's order required the peg tube to be flushed with 60 cc of water before and after medication administration. However, an LPN was observed flushing the tube with only 30 cc of water before and after administering medication. The LPN confirmed that the correct amount should have been 60 cc and acknowledged that insufficient water flushes could lead to complications such as improper medication absorption and failure to clear stomach contents. The Assistant Director of Nursing (ADON) confirmed that nursing staff are expected to check physician orders prior to administering medications and flushes. The ADON also acknowledged that not following the prescribed flush amount could result in the peg tube not being cleared of stomach contents, potentially causing nutritional issues. The facility had an in-service training on medication administration, but it did not provide documentation of material covered specifically related to peg tube orders, and no policies on peg tubes or medication administration were provided.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure medications were stored and labeled in accordance with state laws and accepted standards of pharmacy practice. During an observation, a medicine cup containing a solid-tubular clear substance was found on the dresser of one resident, and another medicine cup containing a solid-tubular white substance was found on the nightstand of another resident. The Director of Nursing (DON) was unable to definitively identify the substances and acknowledged that medications should not have been left in the room. Additionally, a resident self-administered nasal spray incorrectly, administering two sprays in one nostril and one spray in the other, contrary to the prescribed order of one spray in each nostril. The medication cart was also found unlocked with keys in the lock, displaying the resident's personal information on the screen, and left unattended by the LPN, which was confirmed by the DON as a safety concern. Further observations revealed that another medication cart was left unlocked and unattended by an LPN, who was seated at the nurse's station and unable to see the cart. The DON and Assistant Director of Nursing (ADON) confirmed that medication carts should be locked when unattended to prevent unauthorized access. The facility's policy on medication storage states that medications and biologicals should be stored safely, securely, and properly, and that medication supplies should be accessible only to authorized personnel. The policy also specifies that medication carts and supplies should be locked when not attended by authorized personnel.
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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