Bedford Care Center Of Hattiesburg
Inspection history, citations, penalties and survey trends for this long-term care facility in Hattiesburg, Mississippi.
- Location
- 10 Medical Boulevard, Hattiesburg, Mississippi 39401
- CMS Provider Number
- 255158
- Inspections on file
- 15
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Bedford Care Center Of Hattiesburg during CMS and state inspections, most recent first.
Failure to Assist with Advance Directive Formulation: A resident with ESRD and severely impaired cognition had a RR request help with an advance directive, but there was no documentation that staff assisted the family with understanding or formulating one. The daughter reported receiving code status information but not help distinguishing it from an advance directive, and the LMSW confirmed no documented assistance was provided.
Damaged bedroom walls were observed in three resident rooms, including exposed sheetrock, heavy scuffing, and chipped paint behind beds and a recliner. One resident was cognitively intact, while two others had severe cognitive impairment; staff confirmed the wall damage and noted several rooms needed repair and repainting, with the Administrator stating the facility had difficulty hiring a painter.
A resident with schizophrenia, depression, and dementia had a care plan that still listed psychotropic and antidepressant medication interventions even after those medications were discontinued. The order summary showed no active psychotropic or antidepressant orders, and an LPN confirmed the resident was no longer receiving those medications but the care plan had not been resolved and still contained generic medication-related interventions.
Failure to Follow Corticosteroid Inhaler Instructions: An LPN administered a Trelegy Ellipta inhaler to a resident with COPD and did not instruct him to rinse his mouth afterward, despite facility policy and the manufacturer’s directions to rinse and spit out the water after using the corticosteroid inhaler. The LPN confirmed the omission and said she was unaware of the potential side effects; the DON stated staff should instruct residents to rinse their mouths after corticosteroid inhaler use.
Improper Oxygen Storage and Missing Cautionary Signage: An oxygen concentrator and oxygen cylinder were observed stored in a resident’s room without required cautionary signage on the door. The resident had unspecified dementia, a BIMS score of 00, no physician order for oxygen therapy, and staff including an LPN, RN, and DON confirmed the equipment was present and the sign was missing.
Mechanical lift batteries were improperly stored and charged in a biohazard room, a contaminated area, without available cleaning supplies for sanitization before use. This practice violated the facility's Infection Prevention and Control Program policy, as confirmed by interviews with a CNA, the Infection Control Team, and the Administrator.
A resident with Chronic Kidney Disease was discharged from a facility, but the MDS Discharge assessment inaccurately recorded the discharge destination. The resident was discharged home, but the assessment indicated a discharge to a Short-Term General Hospital. The error was identified by the LPN responsible for the MDS section and acknowledged by the DON.
A resident with severely impaired cognition and a preference for Spanish was not provided with culturally specific activities as outlined in her care plan. The facility failed to offer Spanish-language options for television and other activities, despite the resident's dependence on staff for meeting her emotional and social needs.
A facility failed to provide culturally relevant activities for a Spanish-speaking resident with Parkinson's Disease and severe cognitive impairment. Despite the resident's preference for Spanish-language content, the facility did not offer such activities, leaving the resident with English-language television and no culturally specific materials. The deficiency was confirmed through observations, interviews, and record reviews, highlighting a gap in meeting the resident's cultural needs.
A resident with End Stage Renal Disease had inaccurate weight documentation in their medical record, with significant discrepancies not addressed by the facility. The DON was unaware of the weight loss warning, and the Dietary Manager did not identify the error. RN #1 noted the inaccuracies and stated the resident should have been re-weighed, but this did not happen.
Failure to Assist with Advance Directive Formulation
Penalty
Summary
The facility failed to assist a resident's representative with formulating an advance directive in a timely manner for one resident. The resident was admitted with end stage renal disease and had a Quarterly MDS with a BIMS score of 3, indicating severely impaired cognition. The facility policy stated that on admission it would determine whether the resident had executed an advance directive and, if not, whether the resident would like to formulate one, and that the resident's representative would be provided information about the right to refuse treatment and formulate an advance directive. The resident's representative signed an Acknowledgement of Advance Directives Decisions, Rights and Information and requested assistance with formulating an advance directive. During interview, the resident's daughter stated she had received information regarding the resident's code status but had not been assisted with understanding or formulating an advance directive and did not understand the difference between the documents. The LMSW stated she was not the social worker assigned at admission and confirmed there was no documentation showing the resident's representative had been assisted with formulating an advance directive. The Administrator stated she expected staff to assist residents and their representatives with formulating advance directives when assistance is requested.
Damaged Bedroom Walls and Exposed Sheetrock
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment when damaged paint and exposed sheetrock were observed in three resident bedrooms. Resident #1, who was admitted with acute respiratory failure with hypoxia and had a BIMS score of 13 indicating intact cognition, had scarring and exposed sheetrock on the wall behind the recliner in the room. Housekeeping/Maintenance Staff #1 later confirmed paint scratches and exposed sheetrock were present in that room. Resident #79, admitted with unspecified atrial fibrillation and assessed with a BIMS score of 4 indicating severe cognitive impairment, had a heavily scuffed wall behind the bed with extensive scuff marks and visible damage. Resident #87, admitted with dysphasia following cerebral infarction and assessed with a BIMS score of 3 indicating severe cognitive impairment, had chipped paint and scuffs on the wall behind the bed. Housekeeping/Maintenance Staff #1 stated monthly room checks were conducted and that several rooms required repair and repainting, and the Administrator stated the facility had difficulty hiring a painter since approximately November or December 2025 and that the plan was to repair the most damaged rooms first and then continue maintaining paint in other resident rooms.
Care Plan Not Updated After Psychotropic and Antidepressant Medications Were Discontinued
Penalty
Summary
The facility failed to revise Resident #11’s comprehensive care plan after psychotropic and antidepressant medications were discontinued. The resident was admitted with diagnoses including schizophrenia, major depressive disorder, and dementia with psychotic disturbance, mood disturbance, and anxiety. The care plan revision dated 1/9/26 still listed active problems for psychotropic medication use related to impulsive aggression and antidepressant medication use related to depression/anxiety, with interventions to administer those medications and monitor for side effects and effectiveness every shift, even though the resident’s order summary showed no active orders for psychotropic or antidepressant medications related to those diagnoses. The clinical physician orders showed Mirtazapine was discontinued on 6/10/25, Sertraline HCL on 5/30/25, and Risperidone on 12/16/24. The quarterly MDS with ARD 1/27/26 identified the resident as rarely/never understood, severely impaired in daily cognitive decision-making, and coded for non-Alzheimer’s dementia, depression, and schizophrenia. During interview, an LPN confirmed the resident was not receiving psychotropic medications and acknowledged the care plan still contained generic interventions for medications that had been discontinued. The DON stated she expected nursing staff responsible for care planning to revise care plans when physician orders changed and ensure they reflected the resident’s current condition and treatment.
Failure to Follow Corticosteroid Inhaler Instructions
Penalty
Summary
The facility failed to ensure a resident was administered an inhaler medication in accordance with professional standards and manufacturer guidelines during one observed inhaler administration. During observation, an LPN administered Trelegy Ellipta inhaler aerosol, 100-62.5-25 MCG/ACT, one puff orally to Resident #38 and did not instruct the resident to rinse his mouth with water after the medication was inhaled. The facility policy for Administration of Metered-Dose Inhaler stated that if using a corticosteroid, the resident should be allowed to rinse and gargle with water if desired to remove medication from the mouth and back of the throat. The manufacturer’s guidelines for Trelegy Ellipta stated to rinse the mouth with water after inhaling the medication and not to swallow the water. The LPN later confirmed she did not instruct the resident to rinse his mouth after administering the corticosteroid inhaler and stated she was unaware of the potential side effects. The DON stated staff should instruct residents to rinse their mouths after using corticosteroid inhalers and spit the water out to help prevent oral thrush. Resident #38 was admitted with COPD, had a BIMS score of 15 indicating cognitive intactness, and had an order for Trelegy Ellipta one puff inhaled orally daily for COPD.
Improper Oxygen Storage and Missing Cautionary Signage
Penalty
Summary
The facility failed to properly store oxygen cylinders and failed to post required oxygen cautionary signage for one resident. Facility policy stated that oxygen cylinders would be stored in a designated oxygen storage room, but an oxygen concentrator and an oxygen cylinder were observed in the corner of the resident’s room on two separate observations, and there was no oxygen cautionary sign on the door. The resident was found lying in bed asleep during the first observation, and the equipment was not in use at that time. Resident #15 was admitted with a diagnosis of unspecified dementia and had a BIMS score of 00, indicating severely impaired cognition. The medication review showed no physician orders for oxygen therapy, although there was an order for hospice services. During interviews, an LPN, an RN, and the DON each confirmed that the oxygen concentrator and cylinder were in the resident’s room and that no oxygen sign was posted on the door. The LPN and RN stated they did not know why the equipment was there, and the DON stated the equipment should not remain stored in the resident’s room and that oxygen signage should be posted where oxygen equipment is present.
Improper Storage of Mechanical Lift Batteries in Biohazard Room
Penalty
Summary
The facility failed to store reusable medical equipment in a manner that prevents the possible spread of infection. During an observation, it was noted that mechanical lift batteries were stored and charged in a biohazard room on the Rehabilitation Hall. This room is considered a contaminated area, and there were no cleaning supplies available for sanitizing the batteries before they were used on mechanical lifts. This practice is contrary to the facility's Infection Prevention and Control Program policy, which requires that all reusable items and equipment be cleaned in accordance with current procedures. Interviews with a Certified Nurse Aide (CNA) and the Infection Control Team, including the Director of Nursing (DON) and two Registered Nurses (RNs), confirmed the improper storage of the batteries in the biohazard room. The CNA explained that she would place batteries that needed charging in the biohazard room and retrieve charged batteries as needed, without cleaning them. The Infection Control Team acknowledged that items retrieved from the contaminated room should be cleaned before reuse, and they confirmed the absence of cleaning supplies in the area. The Administrator also stated that she expected staff not to store clean items in a contaminated area.
Inaccurate MDS Discharge Assessment
Penalty
Summary
The facility failed to accurately complete a Minimum Data Set (MDS) Discharge assessment for one of the residents. The resident, who was admitted with a diagnosis of Chronic Kidney Disease, was discharged from the facility. The discharge was planned but occurred suddenly due to the resident's insurance status and personal choice. The MDS Discharge assessment inaccurately indicated that the resident was discharged to a Short-Term General Hospital, whereas the resident was actually discharged to his home with his wife. The error was identified during a review of the Discharge MDS, where it was confirmed that the discharge status was incorrectly coded. The Licensed Practical Nurse (LPN) responsible for completing Section A of the MDS initially believed the discharge was coded correctly but later acknowledged the mistake. The Director of Nursing (DON) also recognized the coding error and confirmed that the discharge status was completed in error, emphasizing the expectation of accuracy in all assessments conducted by the facility staff.
Failure to Implement Culturally Specific Care Plan Interventions
Penalty
Summary
The facility failed to implement care plan interventions for a resident who was dependent on staff for meeting emotional, intellectual, physical, and social needs. The care plan included providing the resident with materials for individual activities, such as Spanish word search puzzles and Spanish-speaking programs. However, observations and interviews revealed that the resident, who had a severely impaired cognition and preferred Spanish as her language, was not provided with culturally specific activities. The television in her room was set to an English-language channel, and no attempts were made to explore Spanish-language options. Interviews with the Activities Assistant and Activities Director confirmed that the resident preferred staying in her room and enjoyed activities like music, Spanish puzzles, and watching television. Despite this, no in-room activities catered to her cultural preferences, and the facility lacked culturally specific activities for her. The Administrator and MDS Coordinator acknowledged the issue, emphasizing the importance of following the care plan to provide individualized care and ensure the resident's satisfaction.
Failure to Provide Culturally Relevant Activities for Resident
Penalty
Summary
The facility failed to provide individualized and culturally relevant activities for a Spanish-speaking resident, leading to a deficiency in meeting the resident's needs. The facility's policy mandates that activities should reflect the cultural and religious interests of residents, but this was not implemented for the resident in question. Observations revealed that the resident was often left with the television on an English-language channel, despite her preference for Spanish-language content. Interviews with the Activities Assistant and Activities Director confirmed that no efforts were made to provide culturally specific activities or materials, such as Spanish-language television programs or music, which the resident enjoyed. The resident, who has been diagnosed with Parkinson's Disease and has a severely impaired cognitive status, was admitted to the facility in 2021. Her granddaughter, acting as her Resident Representative, noted that in her four years of visiting, she had not seen any activities that aligned with her grandmother's cultural background. The facility's failure to provide culturally relevant activities was acknowledged by the Administrator, who was unaware of the deficiency until it was brought to her attention. The lack of culturally appropriate activities was also confirmed by a review of the resident's care records, which indicated a preference for Spanish word search puzzles but did not reflect any other culturally relevant activities being provided.
Inaccurate Weight Documentation for a Resident
Penalty
Summary
The facility failed to accurately document a resident's weight in the medical record, which is a violation of their policy on weighing and measuring residents. Resident #49, who was admitted with End Stage Renal Disease, had discrepancies in recorded weights that were not addressed. The facility's policy requires accurate documentation of residents' weights as an indicator of their nutritional status and medical condition. However, a significant weight increase was recorded on 5/17/24, followed by a significant weight loss on 5/20/24, which was not consistent with the resident's typical weight range of 175-192 pounds since admission. Interviews with facility staff revealed a lack of awareness and communication regarding the weight discrepancies. The Director of Nursing was unaware of the weight loss warning as it was not included in the weekly weight reports. The Dietary Manager, responsible for entering weight data into the Minimum Data Set (MDS), stated that she would question any weight that appeared inaccurate but did not identify the error in this case. Registered Nurse #1 acknowledged the inaccuracies in the recorded weights and noted that the resident should have been re-weighed to ensure accuracy, but this did not occur.
Latest citations in Mississippi
A resident with advanced dementia and severe cognitive impairment sustained a bruised left eye and facial bruising after being struck by a CNA. The CNA initially claimed the injury occurred accidentally while pushing the resident to a dining table and denied hitting the resident, but an LPN and another CNA reported that the resident stated she had hit the CNA and was hit back in the eye, demonstrating a slapping motion. Nursing documentation described left orbital ecchymosis, bruising along the bridge of the nose and cheek, tenderness, minimal edema, and the resident’s complaint of soreness, confirming a significant injury resulting from the physical abuse.
The facility failed to protect residents’ right to a dignified and comfortable environment when it did not effectively manage one cognitively impaired resident’s ongoing nighttime yelling, which repeatedly disrupted the sleep of two cognitively intact residents. Staff, including a CNA, the DON, and the Administrator, were aware that this resident, diagnosed with dementia and psychosis, frequently yelled and screamed at night while often sleeping during the day. Progress notes documented nighttime hollering, and interviews confirmed that the disruptive behavior persisted over time, interfering with other residents’ ability to rest.
Surveyors found that the facility failed to protect two residents’ rights to dignity and privacy during routine care. One resident, with moderate cognitive impairment and dependent for toilet hygiene, was observed receiving incontinence care while uncovered, with the room door open and the privacy curtain only partially drawn, allowing visibility into the hallway despite facility policy requiring full privacy. Another resident, dependent for eating and with hemiplegia after a stroke, was assisted with lunch by a CNA who stood over the resident instead of sitting at eye level as required by the facility’s feeding skills checklist. Staff interviews, including with CNAs, an LPN, the DON, and the Administrator, confirmed that existing policies and in-service training directed staff to provide privacy during incontinence care and to sit beside residents when assisting with meals to ensure dignified care.
A resident with epilepsy, skin infection, an upper arm wound, gastrostomy status, and moderate cognitive impairment was observed twice resting in bed with a lunch tray while the call light was not within reach—once on the floor under the bed and once hanging behind the mattress, out of sight. The resident reported being able to use the call light but not knowing where it was. Staff, including CNAs, an LPN, the DON, and the Administrator, stated that call lights are expected to be left within residents’ reach and that training and competencies address this requirement, but there was no specific written policy on call light placement.
A resident with moderate cognitive impairment, dependent for toilet hygiene and with multiple medical conditions, was observed receiving incontinent care in which a CNA removed a urine-soaked brief, changed the bed sheet, and applied a clean brief without performing any required perineal cleansing of the front or back. Facility policy and the peri-care skills checklist specified that male residents must have the perineal area, including the penis, scrotum, and inner thighs, washed, rinsed, and dried during incontinent care. The CNA later acknowledged having been trained and competency-checked on this procedure and knowing cleansing was required. Other staff, including a CNA supervisor, an LPN, the DON, and the Administrator, confirmed that proper incontinent care includes full perineal cleansing in addition to brief changes, establishing that the observed omission did not follow facility policy or professional standards intended to prevent UTIs.
Surveyors found that staff failed to follow infection control practices during PEG tube and wound care. Two residents with PEG tubes had sites with visible brown, crusted or yellowish drainage that had not been cleaned for several days, despite physician orders for daily cleansing and, when indicated, dressings. In another case, a CNA provided peri-care for stool and then assisted with a stage IV sacral pressure ulcer dressing change without changing gloves or performing hand hygiene, contrary to facility policy and staff expectations for aseptic technique.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment when a resident’s room contained odorous soiled linens left on the floor and later placed on furniture with clean clothing, and the bed was made with torn linens exposing the mattress. Other residents reported that housekeeping did not clean under beds, and multiple large dead roaches were repeatedly observed under several beds, with one resident stating he often disposed of dead roaches himself. Residents also reported refusing to use the north shower room due to dirty clothing, feces, and residue on shower chairs and floors; an observation confirmed the presence of soiled clothing, a soiled brief, and unidentified substances on the shower chair and floor, despite staff acknowledging that CNAs were expected to clean and sanitize the shower room after each use.
The facility failed to maintain an effective pest control program, as evidenced by repeated observations of roaches and other insects in multiple resident rooms and common areas. Surveyors found gnats and dead roaches under beds, while several residents reported seeing roaches on ceilings, walls, and floors, including roaches falling onto them at night and having to remove dead roaches themselves. A family member reported bringing her own roach spray due to concerns about roaches in a loved one’s room. During a Resident Council meeting, roaches were seen crawling across the floor, and residents stated that roaches were commonly observed throughout the building. Although the contracted pest control provider reported monthly service focused mainly on entry points and exterior areas and facility staff described processes for reporting pests, the persistent roach activity showed the program was not effectively preventing or controlling pests.
A resident with multiple chronic conditions, who relied on phone contact with a seriously ill significant other, lost access to private communication after her personal cell phone was broken and sent out for repair. Facility policy guarantees residents access to a telephone and private communication, but there was no cordless phone available on the relevant hall, and staff, including the DON, SSD, and Administrator, confirmed there was no convenient method for residents on that hall to make private calls without arranging to use a staff office. This resulted in the resident having no readily available, private telephone option.
A resident with heart failure, chronic kidney disease, hypertension, moderate cognitive impairment, and total dependence on staff for personal and toilet hygiene reported difficulty obtaining assistance with ADLs. Observation revealed the resident had ten long, dirty fingernails extending several millimeters beyond the fingertips with black material underneath, and the resident stated they needed cleaning and cutting. An LPN confirmed the nails were too long and dirty, acknowledged that nursing staff were responsible for daily and weekly fingernail checks and for providing fingernail care as part of ADLs, and noted that such nails could cause skin damage or scratches. The DON and Administrator both confirmed that personal hygiene and grooming are part of ADLs and are expected to be provided for all residents dependent on staff.
Failure to Protect Cognitively Impaired Resident From Physical Abuse by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse, resulting in the resident being struck in the eye by a CNA. Facility records show that a CNA reported to an LPN that the resident had a bruised left eye and initially stated the injury may have occurred while pushing the resident to the dining table due to the resident’s short, stooped posture. The CNA also reported that the resident used a racial slur toward her and that she verbally responded but denied striking the resident. However, subsequent interviews and the facility’s investigation determined that the resident’s injury was not caused by accidental contact with the dining table. Interviews with staff revealed conflicting accounts that led to the conclusion that the resident had been hit. An LPN stated that the resident reported being hit in the eye by the CNA and that another CNA heard a commotion and later observed bruising to the resident’s left eye. When this second CNA asked what happened, the resident reported that she hit the CNA and was hit back in the eye, while making a motion consistent with a slap. The LPN confirmed that the resident gave a similar account to her, indicating that the CNA had physically struck the resident. The resident involved was admitted to the Memory Care Unit with diagnoses including Alzheimer’s disease, cognitive communication deficit, and unspecified dementia with behavioral disturbance, and had a BIMS score of 5 indicating severe cognitive impairment. A nursing progress note documented an acute follow-up assessment of left orbital ecchymosis, describing a dark red circular bruise to the left eye region, dark purple bruising along the lateral bridge of the nose extending to the superior left cheek, tenderness on palpation, minimal edema, and the resident’s complaint that the area was sore. Due to advanced Alzheimer’s disease, the resident was unable to reliably express additional symptoms, but the documented physical findings supported that the resident sustained a significant injury to the eye area as a result of being struck by the CNA.
Failure to Protect Residents’ Right to Rest Due to Unmanaged Nighttime Yelling
Penalty
Summary
The deficiency involves the facility’s failure to ensure a dignified and comfortable environment by not effectively addressing ongoing disruptive nighttime behaviors of one resident that interfered with other residents’ ability to rest. Resident #1, admitted with diagnoses including Psychosis and Dementia and a BIMS score of 4 indicating severely impaired cognition, had documented episodes of hollering and yelling during nighttime hours, as noted in progress notes on 3/12/26 and 3/13/26. Interviews with cognitively intact residents, Resident #2 and Resident #3 (both with BIMS scores of 15), revealed that they frequently experienced disrupted sleep due to Resident #1 yelling loudly at night, while the environment was generally quiet during the day. Staff interviews confirmed awareness of the pattern of behavior. CNA #1, who worked both day and night shifts, reported that Resident #1 frequently yelled and screamed at intervals throughout the night and was generally quiet and often slept during the day, with staff assisting the resident out of bed into a geri-chair during both day and nighttime hours. The DON acknowledged the facility was aware of Resident #1’s increased nighttime yelling and extended daytime rest, attributing it to the resident’s Dementia and Psychosis, and stated that interventions such as monitoring, repositioning, offering care, and attempts at redirection had not stopped the behaviors. The Administrator also confirmed awareness of concerns that nighttime noise from Resident #1 affected other residents’ ability to rest. Despite this awareness and ongoing complaints from other residents, the disruptive nighttime yelling continued, resulting in a failure to uphold residents’ rights to a dignified existence and a comfortable environment.
Failure to Ensure Privacy and Dignified Care During Incontinence Care and Feeding
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were treated with dignity and provided privacy during care, as required by resident rights policies and skills checklists. The facility’s Nursing Facility Resident Rights policy guaranteed residents the right to be treated with dignity, courtesy, and respect, and to have privacy during personal care. Facility skills checklists for feeding and peri/incontinent care specified that staff should sit facing residents at eye level when feeding and provide privacy by drawing curtains and closing doors during incontinence care. For Resident #2, surveyors observed a CNA providing incontinent care without closing the resident’s room door and with the privacy curtain only partially drawn. From the surveyor’s position at the bottom right corner of the bed, it was possible to see into the hallway while the resident was uncovered and exposed. Resident #2’s records showed admission with diagnoses including epilepsy, infection of the skin and subcutaneous tissue, an open wound of the left upper arm, and gastrostomy status. A recent MDS assessment documented a BIMS score of 11, indicating moderate cognitive impairment, and that the resident was dependent for toilet hygiene. The CNA later confirmed awareness that incontinence care required provision of privacy and that she had been trained and competency-checked on this requirement. For Resident #3, surveyors observed a CNA assisting the resident with eating while standing over the resident rather than sitting beside her, contrary to the facility’s feeding skills checklist and training. The DON intervened during the observation and instructed the CNA that staff were to sit next to residents while assisting with eating. The CNA stated she had forgotten to sit beside the resident. Resident #3’s records showed recent admission with diagnoses of cerebral infarction (stroke), anemia, and hemiplegia and hemiparesis affecting the right dominant side, and a baseline care plan indicating the resident was dependent for eating. Other staff interviews, including with a CNA supervisor, an LPN, the DON, and the Administrator, confirmed that staff were trained at least monthly on residents’ rights, respectful and dignified care, provision of privacy during incontinence care, and the expectation that staff sit beside residents when assisting with eating.
Failure to Maintain Accessible Call Light for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was maintained within reach as required by the facility’s feeding skills checklist. The skills checklist for feeding a resident specifies that staff must leave the call light within the resident’s reach after feeding. For Resident #2, surveyors observed on two separate occasions that the call light was not accessible. On one observation, the resident was awake in bed with a lunch tray on the overbed table, and the call light was found lying on the floor under the head of the bed. The resident stated he could use his call light but did not know where it was. On a subsequent observation, Resident #2 was again in bed with a lunch tray in front of him, and the call light was hanging behind the mattress at the head of the bed, out of his sight and reach. The resident again stated he could use the call light but did not know where it was. Record review showed the resident had epilepsy, an infection of the skin and subcutaneous tissue, an open wound of the left upper arm, gastrostomy status, and a BIMS score of 11 indicating moderate cognitive impairment. Staff interviews with CNAs, an LPN, the DON, and the Administrator confirmed that call lights were expected to be within residents’ reach and answered timely, and that staff had received in-service training and competency checks on leaving call lights within reach. The Administrator also confirmed there was no specific written policy regarding call light placement.
Failure to Provide Required Perineal Cleansing During Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to provide incontinent care in accordance with its own peri-care policy and professional standards of practice for a male resident who was dependent for toilet hygiene. The facility’s written policy for peri/incontinent care for male residents, revised in January 2023, required cleansing of the perineal area starting at the urethra and working outward, including washing and rinsing the penis, scrotum, inner thighs, and perineal area front and back, followed by thorough drying. Record review showed the resident had diagnoses including epilepsy, infection of the skin and subcutaneous tissue, an open wound of the left upper arm, and gastrostomy status, and a Quarterly MDS with a BIMS score of 11 indicating moderate cognitive impairment, with the resident assessed as dependent for toilet hygiene. On the observed date and time, CNA #1 provided incontinent care to this resident by removing a wet urine-soaked brief, changing the fitted sheet, and applying a clean, dry brief without cleansing the resident’s perineal area, front or back, contrary to facility policy. During a subsequent interview, CNA #1 acknowledged she had received in-service training and competency check-offs on peri-care and knew she was supposed to cleanse the perineal area but did not do so, stating she was nervous. Additional interviews with CNA #2 (CNA supervisor and scheduler), an LPN, the DON, and the Administrator confirmed that staff were trained using the Peri Care–Incontinent Care Skills Checklist and that proper incontinent care includes cleansing the perineal area, front and back, in addition to changing the brief. The failure to perform the required cleansing during incontinent care constituted the cited deficiency related to prevention of urinary tract infections.
Failure to Maintain Infection Control Practices During PEG Tube and Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program by not maintaining aseptic technique and not providing ordered dressing changes for residents with PEG tubes and a sacral pressure injury. Facility policies on infection control and clean dressing changes required wound care to be provided in a manner that decreases the potential for infection and cross-contamination, including removal of soiled dressings with gloves, discarding gloves, performing hand hygiene, and donning clean gloves before continuing care. The peri-care audit tool also required glove removal, hand hygiene, and re-gloving after peri-care. These standards were not followed during multiple observed care episodes. For one resident with a PEG tube and diagnoses including Alzheimer’s disease, functional quadriplegia, and gastrostomy status, surveyors observed the PEG tube site without a dressing and with a yellowish-brown substance beneath and around the external skin disk extending about one-fourth inch onto surrounding skin. A CNA and an LPN both confirmed there was no dressing in place and acknowledged the drainage at the site. The LPN stated PEG tube site care should be completed daily and as needed for increased drainage and acknowledged that, with no dressing and the amount of drainage present, there was no way to tell when the site was last cleaned. Record review showed a physician order, effective several months prior, for daily cleansing of the PEG tube stoma with normal saline, patting dry, and applying a dry drain dressing to avoid skin breakdown. For another resident with severe protein-calorie malnutrition and gastrostomy status, the PEG tube site was observed with thick brown, crusted substance beneath the external skin disk extending approximately one-half to three-fourths of an inch to the surrounding area. The resident reported the site had not been cleaned in about three days and later stated they might have to clean it themselves. Follow-up observations confirmed the site remained unclean with visible drainage, and an LPN and the DON both confirmed the presence of thick, brown drainage and that the site had not been cleaned in several days, despite an order for daily cleansing with soap and water, rinsing, patting dry, and leaving open to air or applying a dry dressing if drainage was present. In a separate observation involving a resident with a stage IV sacral pressure ulcer and severe cognitive impairment, a CNA provided peri-care for stool soiling, then immediately assisted with wound care using the same gloves worn during peri-care, without performing hand hygiene or changing gloves. The CNA, treatment nurse, DON, and ADON all acknowledged that hand hygiene and glove change should have occurred between peri-care and wound care and that this represented an infection control concern.
Failure to Maintain Clean Resident Rooms and Shower Facilities
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by its Resident Rights & Quality of Life Policy. For one resident, surveyors observed a bag of odorous soiled linens resting on the floor of the room, and the resident’s bed was made with a bedspread that had a football-sized hole exposing the mattress. The resident, who was cognitively intact with a BIMS score of 14 and had Type 2 Diabetes Mellitus, reported that it was not unusual for bags of soiled linens to be left on the floor and for bedding to be damaged. A CNA confirmed that soiled linens were commonly left in bags on the floor after morning care and that torn bedding should not be used, and later placed the bag of soiled linens on the resident’s furniture where his clean clothing was hanging. The resident remained upset the following day, and a dead roach was observed under his bed near the headboard. Additional deficiencies were identified in other resident rooms. One resident with End Stage Renal Disease and a severely impaired cognition (BIMS score of 5) reported that housekeeping did not clean under the bed; surveyors observed three large dead roaches under the bed, which remained there the following day. When the Housekeeping Supervisor later observed the room, five dead roaches were present under the bed, and he stated the area should not have been in that condition. Another resident, with a diffuse traumatic brain injury and a moderately impaired cognition (BIMS score of 10), reported frequently picking up and disposing of dead roaches himself because staff did not remove them, and a large dead roach was observed under his bed. The facility also failed to maintain a clean and sanitary north shower room. During a Resident Council interview, multiple cognitively intact and moderately impaired residents reported refusing to use the shower room due to cleanliness concerns, including observations of dirty clothing, feces, and residue on shower chairs and floors. A housekeeper stated that while she cleaned the shower rooms multiple times a day, CNAs were responsible for cleaning and sanitizing the shower room after each use and that she had observed occasions when CNAs failed to do so. A subsequent observation of the north shower room revealed soiled clothing, including a soiled brief, on a shower chair, a yellow fluid-like substance on the floor and shower chair, and a white powdery substance on the floor, with no staff present. The Social Services Assistant, DON, and Administrator each acknowledged that staff were expected to clean and sanitize the shower room after each use.
Ongoing Roach Activity Demonstrates Ineffective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program as required by its pest control policy dated 9/1/2014, which states the center will maintain an ongoing program to keep the building free of insects and rodents. Surveyors observed multiple instances of roach and insect activity in resident rooms and common areas. In one cognitively intact resident’s room, gnats were seen flying and a dead roach was later found under the bed near the headboard. Another resident’s room contained three large dead roaches under the bed on two consecutive days; this resident reported that roaches were regularly seen in the room, especially at night, crawling on the ceiling and falling onto him and his roommate, and that staff had been notified but he had not seen staff respond to assess or treat the issue. A third resident reported seeing roaches on the ceiling and under the bed and stated he often removed dead roaches himself because staff did not; a large dead roach was observed under his bed. A family member of another resident reported feeling it was necessary to bring her own roach spray due to concerns about roaches in the resident’s room and stated she was told she could not keep the spray in the room, expressing concern that the roach problem needed to be addressed. During a Resident Council meeting, two large roaches were observed crawling across the floor, and residents reported that roaches were commonly seen in rooms and common areas, including on walls, ceilings, and floors, particularly at night. The contracted pest control provider reported he provides monthly services, focusing on different areas each visit, primarily treating entry points and exterior areas, and stated he had not personally observed roaches and received only occasional complaints. Facility leadership, including the housekeeping supervisor, DON, and Maintenance Director, described expectations that staff report pest sightings and that pest control services are available monthly and as needed, but the ongoing presence of roaches and dead insects in resident rooms and common areas demonstrated that the pest control program was not effectively preventing or controlling pests.
Failure to Ensure Resident Access to Private Telephone Communication
Penalty
Summary
The facility failed to ensure a resident’s right to reasonable access to and privacy in the use of a telephone for communication. Facility policy on Resident Rights, revised December 2016, states that residents are guaranteed access to a telephone, mail, and email, and the ability to communicate in person and by mail, email, and telephone with privacy. Resident #1 was admitted on 12/18/24 with diagnoses including Sjogren syndrome, rheumatoid arthritis, chronic kidney disease, and morbid obesity. During an interview, the resident reported that she had dropped and broken her personal cellular telephone, which she had used for private communication, and that the facility did not have any telephone that was convenient for her to use privately. She stated that no staff had offered her the use of a staff office or any other mechanism for private communication, and she was upset because she relied on telephone contact with her significant other, who had cancer and was unable to visit. Observations and staff interviews confirmed the lack of accessible, private telephone options for residents on South Hall. An observation on the 100 Hall revealed there was no cordless telephone available for resident use. The DON confirmed that the facility did not have a method to provide residents on South Hall with private communication without first making arrangements or an appointment to use a staff office, and that the cordless telephones in the facility did not have sufficient range to reach South Hall. The SSD confirmed there were no cordless telephones at the South Hall nurses’ station that could be taken to residents’ rooms and acknowledged that Resident #1’s cell phone had been broken and sent out for repair. The Administrator also confirmed that residents on South Hall did not have a method for private communication without prior arrangements and acknowledged that access to private communication is a guaranteed resident right.
Failure to Provide Adequate ADL Assistance for Personal Hygiene
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) to maintain personal hygiene for one resident who was dependent on staff for care. Facility policy on ADLs, revised March 2018, stated that residents unable to carry out ADLs independently would receive services necessary to maintain good grooming and personal and oral hygiene. Record review showed the resident was admitted with heart failure, chronic kidney disease, and hypertension, had a BIMS score of 12 indicating moderate cognitive impairment, was always incontinent of bowel and bladder, and required substantial/maximal assistance for personal hygiene and was dependent for toilet hygiene. A complainant reported that the resident had expressed difficulty getting staff to provide assistance with ADLs. During an observation and interview with the resident, accompanied by an LPN, the resident reported ongoing difficulty obtaining assistance with ADLs. The surveyor observed that the resident had ten long, dirty fingernails protruding 3.0 to 3.5 millimeters past the fingertips, with a black substance beneath all fingernails; the resident stated they needed cleaning and cutting and were too long. The LPN described the fingernails as too long and dirty, confirmed that nursing staff were responsible for checking fingernails daily during care and weekly during body audits, and acknowledged that staff were responsible for providing fingernail care as part of ADLs. The LPN also confirmed that long, dirty, unkempt fingernails had the potential to cause damage or scratches to the resident’s skin. The DON stated she was not aware of any complaints from the resident but confirmed her expectation that ADLs for residents dependent on staff for personal hygiene would be maintained and provided as needed, and that licensed nurses trimmed fingernails for some residents while any nursing staff could clean under fingernails. The Administrator confirmed that personal hygiene and grooming were part of resident ADLs and were expected to be provided for all dependent residents.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
