Billdora Senior Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Tylertown, Mississippi.
- Location
- 314 Enochs St, Tylertown, Mississippi 39667
- CMS Provider Number
- 255243
- Inspections on file
- 17
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 4 (1 serious)
Citation history
Health deficiencies cited at Billdora Senior Care during CMS and state inspections, most recent first.
A resident with a stage 3 sacral pressure ulcer moaned, yelled out, and showed facial grimacing during wound care, but pain medication was not provided in a timely manner before treatment. Record review showed repeated pain scores over several months with no documented pain medication administration, and staff interviews confirmed the resident had ongoing pain during wound care and that stronger pain control was needed than acetaminophen alone.
Staff failed to follow hand hygiene and EBP during wound care and peri care for a resident with a stage 3 sacral pressure ulcer. An RN and the IP nurse were observed missing hand hygiene before glove use, leaving and re-entering the room while handling supplies, and performing peri care without a gown. The RN, IP nurse, and DON all confirmed the hand hygiene and gown use lapses during direct care.
A resident with severe cognitive impairment, dementia with psychosis, and a known history of wandering was admitted with orders for monitoring of wandering and elopement, and could ambulate independently. The next morning, the resident was last seen in the room and hallway by an LPN, then could not be found by a CNA when lunch was being served, prompting a missing resident code and search. Security footage and staff interviews showed that a dietary aide, who did not recognize the resident or verify with nursing, entered the numeric code on the front entrance keypad and allowed the resident to exit unaccompanied and unsupervised. The facility’s elopement policy required adequate supervision and use of door locks/alarms and systematic monitoring for at-risk residents, but the facility relied on staff-held door codes and did not have a two-part safe wandering system; the resident was later found by maintenance staff about half a mile away and returned without injury.
The facility failed to provide residents with mail on Saturdays, as one resident reported not receiving mail on weekends. The facility's policy requires residents to receive mail, but interviews revealed a lack of clarity and execution regarding weekend mail distribution. The Activities Director handles mail during weekdays, but there is no clear protocol for weekends, leading to mail being stored until Monday. Staff interviews indicated confusion and inconsistency in the process, with many unaware of any responsibility for weekend mail distribution.
A resident reported a missing Saints jersey, but the facility failed to resolve the grievance promptly. Social Services did not follow up on the status of the replacement, and the Nursing Home Administrator did not verify the correct size before ordering. The resident's representative confirmed the jersey was missing, and the facility's actions reflect a deficiency in addressing grievances effectively.
A facility failed to provide a written reason for a resident's hospital discharge to the resident and/or their representative. The resident, admitted with Acute Respiratory Failure and Congestive Heart Failure, was discharged to the hospital without the required reason in the transfer letter. The Social Service Director and Administrator were unaware of the requirement, with the latter mistakenly believing it would violate HIPAA.
A facility did not place an 'Oxygen in Use' sign on the door of a resident receiving oxygen therapy, as required by policy. This was confirmed by an LPN and the DON, who stated the sign should have been posted upon the resident's admission to alert staff and visitors. The resident had diagnoses of dysphagia and shortness of breath and was unable to complete a mental status interview.
Failure to Provide Pain Medication Before Wound Care
Penalty
Summary
The facility failed to provide sufficient pain medication prior to wound care for a resident with a stage 3 sacral pressure ulcer. During wound care, the resident moaned, yelled out, and displayed facial grimacing throughout the procedure while the RN cleaned the wound. The resident had been given acetaminophen about 10 minutes before wound care began, and the record showed no pain medication had been ordered prior to that date despite repeated documentation of pain over several months. The resident was admitted with a stage 3 sacral pressure ulcer and had wound care orders for daily cleansing, collagen, calcium alginate, betadine to the peri-wound skin, and a silicone border dressing. The record review showed multiple pain assessments and vital sign summaries documenting pain levels ranging from 3 to 6 on several dates, with no documentation that pain medication was administered for those episodes. The EMAR from admission through the day before the observation showed no pain medications given, and the resident’s MDS indicated pain medication was not received. During interviews, the RN stated the resident always moaned and hollered during wound care and acknowledged she had not obtained an order for pain medication during the prior months. The LPN, IP nurse, CNA, DON, and physician all confirmed the resident showed signs of pain during wound care and that pain medication should have been provided before treatment. The physician stated the wound was painful and worsening and that the resident required more medication than acetaminophen, and later changed the pain medication so the resident would not be in pain during wound care.
Failure to Follow Hand Hygiene and EBP During Wound and Peri Care
Penalty
Summary
The facility failed to ensure staff followed proper hand hygiene and Enhanced Barrier Precautions (EBP) during wound care and peri care for one resident with a stage 3 pressure ulcer of the sacral region. During an observed wound care treatment, RN #2 donned a gown but did not don gloves before touching the feeding pump and did not perform hand hygiene before applying gloves. RN #1 also removed gloves, left the room to retrieve supplies, returned and donned gloves without performing hand hygiene, and later forgot to bring hand sanitizer into the room. After removing gloves again, RN #1 went to the cart for hand sanitizer, then continued wound care after handling saline and gauze in a manner corrected by RN #2. RN #1 did not sanitize hands after removing gloves before returning to the room to continue care. After wound care, RN #1 removed the gown and gloves and left the room to gather peri care supplies, then returned and began peri care to the buttocks area without putting on a gown. In interview, RN #1 confirmed she had to leave the room several times because she did not have all supplies needed, acknowledged she did not have a gown during peri care, and stated she should have had one on. RN #2 confirmed she did not realize RN #1 had not washed her hands a couple of times and stated the resident had a higher risk of infection from RN #1 not wearing a gown during peri care. The DON confirmed RN #2 should have washed her hands before applying gloves and that RN #1 should have worn a gown for EBP during direct care, including peri care.
Elopement of Cognitively Impaired Resident Due to Inadequate Supervision at Secured Exit
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision to prevent an elopement for one resident who was newly admitted with dementia, delusional disorder, hallucinations, and a documented history of wandering. The resident’s admission MDS showed a BIMS score of 3, indicating severe cognitive impairment, and identified a history of wandering, while functional assessment documented that the resident could ambulate independently for 150 feet. The admission history and physical from the community setting described dementia with agitation and psychosis, aggressive behaviors and irritability related to attempts to cross the street, and agitation when unable to perform desired activities such as going across the road. The physician had previously discussed safety issues with the family and recommended additional door locks at home to prevent wandering and leaving the house. Upon admission, the facility had a physician order to monitor wandering and elopement for 14 days and an active order to monitor behavior each shift for anxiety, restlessness, and pacing. On the morning following admission, the resident was observed by an LPN at approximately 10:35–10:40 a.m. sitting on the side of the bed and had been seen walking in the hallway and to the nurse’s station earlier in the day. Around 11:30–11:40 a.m., when staff were preparing lunch, a CNA was unable to locate the resident in the room, dining room, or therapy area and notified nursing staff that the resident might be missing. A brief search inside the facility was conducted before the DON was notified and a missing resident code was called overhead. Staff then initiated a broader search of the building and surrounding outside areas after learning the identity of the missing resident. The Administrator later reviewed security camera footage and determined that a dietary aide had assisted the resident with the front entrance door. The dietary aide reported that she had seen the resident at the front door, did not know who he was, and entered the numeric code into the keypad to disengage the lock, allowing the resident to exit the building unaccompanied and unsupervised. The facility’s elopement and wandering policy stated that residents at risk for elopement were to receive adequate supervision, that interventions were to be added to the care plan and communicated to staff, and that door locks/alarms and a systematic approach to monitoring and managing residents at risk were to be used. At the time of the incident, the facility relied on staff-held numeric codes for exit doors and did not have a two-part safe wandering system with resident-worn monitors and corresponding door monitors. The resident was ultimately located by the maintenance technician approximately 0.5 miles from the facility, sitting on the steps of a local business, and was returned to the facility. Interviews with staff confirmed the sequence of events and the lack of recognition of the resident’s identity and risk status at the exit door. The Administrator confirmed that the dietary aide had not checked with nursing staff before entering the door code and allowing the resident to leave. The maintenance technician stated that, regardless of the route taken, the resident would have had to cross two of the busiest streets in town to reach the location where he was found. At the time he was located, the resident’s clothing and shoes were clean and dry, and staff assessments upon return noted no injuries or pain. The facility’s failure to ensure that a resident with known severe cognitive impairment and a history of wandering was adequately supervised, and to prevent an untrained staff member from facilitating his exit through a secured door, resulted in the resident leaving the facility unnoticed and unsupervised.
Removal Plan
- Initiated Code [NAME] (missing resident) and began facility-wide search when Resident #1 could not be located.
- Notified the Administrator immediately via Code [NAME].
- Notified the physician.
- Notified the resident representative.
- Completed a head count to ensure all other residents were accounted for.
- Expanded the search throughout the facility.
- Expanded the search outside the facility and assigned maintenance staff to search by vehicle.
- Located Resident #1 off-site and returned the resident safely to the facility.
- Physician assessed and evaluated Resident #1 upon return; no injury noted.
- LPN performed a full body audit upon return; no injury noted.
- RN performed a pain assessment upon return; no pain verbalized.
- Placed Resident #1 on one-on-one (1:1) monitoring upon return.
- Reassessed Resident #1 for wander and elopement risk (moderate risk).
- Updated Resident #1 care plan to include one-on-one (1:1) monitoring.
- Verified all doors were functioning properly.
- Audited residents to identify risk for wandering and elopement and identified additional residents at risk who continued to be monitored.
- Reported the event to the Mississippi State Department of Health Hotline.
- Reported the event on the Attorney General Medicaid Fraud Site.
- Reviewed the Wander and Elopement Binder to ensure updated risk assessments and current photos for residents at risk.
- Updated colored signage instructing staff to check with nursing before allowing anyone out the door.
- Suspended the Dietary Aide pending investigation and terminated employment.
- Held an emergency QAPI meeting.
- Completed facility-wide education/in-services on the Elopement and Wandering Residents Policy, Code [NAME] Policy, identifying residents at risk for elopement, and resident identification protocols.
- Conducted elopement drills on each shift.
- Implemented ongoing monitoring of staff competency/knowledge regarding wandering risk and safety awareness using scheduled knowledge testing.
- Implemented monitoring of the Elopement Binder to ensure each at-risk resident has a current photograph and up-to-date risk assessment.
- Implemented monitoring of residents at risk for wandering/elopement to ensure alert band placement, with planned replacement by safe wandering system bracelet placement upon installation.
Failure to Distribute Mail on Weekends
Penalty
Summary
The facility failed to provide residents with mail on Saturdays, as evidenced by the experience of one resident, who reported not receiving mail on weekends. The facility's policy, revised in August 2024, mandates that residents have the right to receive mail, but interviews with staff and residents revealed a lack of clarity and execution regarding mail distribution on weekends. The Activities Director is responsible for distributing mail during weekdays, but there is no clear protocol for weekend mail distribution, leading to mail being stored until Monday. Interviews with various staff members, including the Administrator, front desk receptionist, LPN, CNA, Social Services Director, and RN, indicated confusion and inconsistency in the process of mail distribution on weekends. The Administrator believed that mail was distributed by nurses or CNAs on weekends, but staff interviews contradicted this, with many stating they were unaware of any such responsibility. The Director of Nursing assumed social services or activities staff handled weekend mail, but this was not confirmed by the staff involved. The resident in question, who is cognitively intact, confirmed that mail received on weekends is not delivered until the following Monday.
Failure to Resolve Grievance for Missing Property
Penalty
Summary
The facility failed to promptly resolve a grievance related to a resident's missing property, specifically a Saints jersey, for one of the sampled residents. The resident reported the missing jersey to Social Services (SS) late in 2024, during football season. SS initially informed the resident that a replacement jersey would be ordered, but later stated in January 2025 that it needed to be reordered. Despite these assurances, SS did not follow up with the resident regarding the status of the jersey. Additionally, there was no record of the grievance in the grievance book, indicating a lack of proper documentation and follow-up. The Nursing Home Administrator (NHA) was informed of the issue by SS but had not contacted the resident's family to verify ownership of the jersey or the correct size before attempting to order a replacement. The resident's representative confirmed the jersey was missing and that a 2XL jersey, which the NHA planned to order, would not fit the resident. The resident's inventory sheet from November 2024 documented the presence of the jersey, and the resident was cognitively intact with a BIMS score of 15. The facility's failure to resolve the grievance promptly and accurately reflects a deficiency in safeguarding the resident's property and addressing grievances effectively.
Failure to Provide Reason for Hospital Discharge
Penalty
Summary
The facility failed to provide written notification of the reason for a resident's hospital discharge to the resident and/or Resident Representative (RR). This deficiency was identified for a resident who was admitted with diagnoses including Acute Respiratory Failure with Hypoxia and Acute Systolic Congestive Heart Failure. The resident was discharged to the hospital, but the transfer/discharge letter did not include the reason for the transfer. The Social Service Director, responsible for mailing these letters, was unaware of the requirement to include the reason for the transfer/discharge. The Administrator also expressed a lack of awareness regarding the regulation, mistakenly believing that including such information would violate HIPAA.
Failure to Display Oxygen in Use Sign for Resident
Penalty
Summary
The facility failed to adhere to its policy regarding oxygen therapy for a resident requiring such care. During a survey observation, it was noted that a resident receiving oxygen therapy at a flow rate of 3 milliliters per hour did not have an 'Oxygen in Use' sign on the door of their room. This omission was confirmed by both an LPN and the Director of Nursing, who acknowledged that the signage should have been placed upon the resident's admission to alert staff and visitors to the presence of oxygen and prevent fire hazards. The resident, who was admitted with diagnoses including dysphagia and shortness of breath, was unable to complete a mental status interview as indicated by their Minimum Data Set assessment.
Latest citations in Mississippi
A resident with advanced dementia and severe cognitive impairment sustained a bruised left eye and facial bruising after being struck by a CNA. The CNA initially claimed the injury occurred accidentally while pushing the resident to a dining table and denied hitting the resident, but an LPN and another CNA reported that the resident stated she had hit the CNA and was hit back in the eye, demonstrating a slapping motion. Nursing documentation described left orbital ecchymosis, bruising along the bridge of the nose and cheek, tenderness, minimal edema, and the resident’s complaint of soreness, confirming a significant injury resulting from the physical abuse.
The facility failed to protect residents’ right to a dignified and comfortable environment when it did not effectively manage one cognitively impaired resident’s ongoing nighttime yelling, which repeatedly disrupted the sleep of two cognitively intact residents. Staff, including a CNA, the DON, and the Administrator, were aware that this resident, diagnosed with dementia and psychosis, frequently yelled and screamed at night while often sleeping during the day. Progress notes documented nighttime hollering, and interviews confirmed that the disruptive behavior persisted over time, interfering with other residents’ ability to rest.
Surveyors found that the facility failed to protect two residents’ rights to dignity and privacy during routine care. One resident, with moderate cognitive impairment and dependent for toilet hygiene, was observed receiving incontinence care while uncovered, with the room door open and the privacy curtain only partially drawn, allowing visibility into the hallway despite facility policy requiring full privacy. Another resident, dependent for eating and with hemiplegia after a stroke, was assisted with lunch by a CNA who stood over the resident instead of sitting at eye level as required by the facility’s feeding skills checklist. Staff interviews, including with CNAs, an LPN, the DON, and the Administrator, confirmed that existing policies and in-service training directed staff to provide privacy during incontinence care and to sit beside residents when assisting with meals to ensure dignified care.
A resident with epilepsy, skin infection, an upper arm wound, gastrostomy status, and moderate cognitive impairment was observed twice resting in bed with a lunch tray while the call light was not within reach—once on the floor under the bed and once hanging behind the mattress, out of sight. The resident reported being able to use the call light but not knowing where it was. Staff, including CNAs, an LPN, the DON, and the Administrator, stated that call lights are expected to be left within residents’ reach and that training and competencies address this requirement, but there was no specific written policy on call light placement.
A resident with moderate cognitive impairment, dependent for toilet hygiene and with multiple medical conditions, was observed receiving incontinent care in which a CNA removed a urine-soaked brief, changed the bed sheet, and applied a clean brief without performing any required perineal cleansing of the front or back. Facility policy and the peri-care skills checklist specified that male residents must have the perineal area, including the penis, scrotum, and inner thighs, washed, rinsed, and dried during incontinent care. The CNA later acknowledged having been trained and competency-checked on this procedure and knowing cleansing was required. Other staff, including a CNA supervisor, an LPN, the DON, and the Administrator, confirmed that proper incontinent care includes full perineal cleansing in addition to brief changes, establishing that the observed omission did not follow facility policy or professional standards intended to prevent UTIs.
Surveyors found that staff failed to follow infection control practices during PEG tube and wound care. Two residents with PEG tubes had sites with visible brown, crusted or yellowish drainage that had not been cleaned for several days, despite physician orders for daily cleansing and, when indicated, dressings. In another case, a CNA provided peri-care for stool and then assisted with a stage IV sacral pressure ulcer dressing change without changing gloves or performing hand hygiene, contrary to facility policy and staff expectations for aseptic technique.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment when a resident’s room contained odorous soiled linens left on the floor and later placed on furniture with clean clothing, and the bed was made with torn linens exposing the mattress. Other residents reported that housekeeping did not clean under beds, and multiple large dead roaches were repeatedly observed under several beds, with one resident stating he often disposed of dead roaches himself. Residents also reported refusing to use the north shower room due to dirty clothing, feces, and residue on shower chairs and floors; an observation confirmed the presence of soiled clothing, a soiled brief, and unidentified substances on the shower chair and floor, despite staff acknowledging that CNAs were expected to clean and sanitize the shower room after each use.
The facility failed to maintain an effective pest control program, as evidenced by repeated observations of roaches and other insects in multiple resident rooms and common areas. Surveyors found gnats and dead roaches under beds, while several residents reported seeing roaches on ceilings, walls, and floors, including roaches falling onto them at night and having to remove dead roaches themselves. A family member reported bringing her own roach spray due to concerns about roaches in a loved one’s room. During a Resident Council meeting, roaches were seen crawling across the floor, and residents stated that roaches were commonly observed throughout the building. Although the contracted pest control provider reported monthly service focused mainly on entry points and exterior areas and facility staff described processes for reporting pests, the persistent roach activity showed the program was not effectively preventing or controlling pests.
A resident with multiple chronic conditions, who relied on phone contact with a seriously ill significant other, lost access to private communication after her personal cell phone was broken and sent out for repair. Facility policy guarantees residents access to a telephone and private communication, but there was no cordless phone available on the relevant hall, and staff, including the DON, SSD, and Administrator, confirmed there was no convenient method for residents on that hall to make private calls without arranging to use a staff office. This resulted in the resident having no readily available, private telephone option.
A resident with heart failure, chronic kidney disease, hypertension, moderate cognitive impairment, and total dependence on staff for personal and toilet hygiene reported difficulty obtaining assistance with ADLs. Observation revealed the resident had ten long, dirty fingernails extending several millimeters beyond the fingertips with black material underneath, and the resident stated they needed cleaning and cutting. An LPN confirmed the nails were too long and dirty, acknowledged that nursing staff were responsible for daily and weekly fingernail checks and for providing fingernail care as part of ADLs, and noted that such nails could cause skin damage or scratches. The DON and Administrator both confirmed that personal hygiene and grooming are part of ADLs and are expected to be provided for all residents dependent on staff.
Failure to Protect Cognitively Impaired Resident From Physical Abuse by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse, resulting in the resident being struck in the eye by a CNA. Facility records show that a CNA reported to an LPN that the resident had a bruised left eye and initially stated the injury may have occurred while pushing the resident to the dining table due to the resident’s short, stooped posture. The CNA also reported that the resident used a racial slur toward her and that she verbally responded but denied striking the resident. However, subsequent interviews and the facility’s investigation determined that the resident’s injury was not caused by accidental contact with the dining table. Interviews with staff revealed conflicting accounts that led to the conclusion that the resident had been hit. An LPN stated that the resident reported being hit in the eye by the CNA and that another CNA heard a commotion and later observed bruising to the resident’s left eye. When this second CNA asked what happened, the resident reported that she hit the CNA and was hit back in the eye, while making a motion consistent with a slap. The LPN confirmed that the resident gave a similar account to her, indicating that the CNA had physically struck the resident. The resident involved was admitted to the Memory Care Unit with diagnoses including Alzheimer’s disease, cognitive communication deficit, and unspecified dementia with behavioral disturbance, and had a BIMS score of 5 indicating severe cognitive impairment. A nursing progress note documented an acute follow-up assessment of left orbital ecchymosis, describing a dark red circular bruise to the left eye region, dark purple bruising along the lateral bridge of the nose extending to the superior left cheek, tenderness on palpation, minimal edema, and the resident’s complaint that the area was sore. Due to advanced Alzheimer’s disease, the resident was unable to reliably express additional symptoms, but the documented physical findings supported that the resident sustained a significant injury to the eye area as a result of being struck by the CNA.
Failure to Protect Residents’ Right to Rest Due to Unmanaged Nighttime Yelling
Penalty
Summary
The deficiency involves the facility’s failure to ensure a dignified and comfortable environment by not effectively addressing ongoing disruptive nighttime behaviors of one resident that interfered with other residents’ ability to rest. Resident #1, admitted with diagnoses including Psychosis and Dementia and a BIMS score of 4 indicating severely impaired cognition, had documented episodes of hollering and yelling during nighttime hours, as noted in progress notes on 3/12/26 and 3/13/26. Interviews with cognitively intact residents, Resident #2 and Resident #3 (both with BIMS scores of 15), revealed that they frequently experienced disrupted sleep due to Resident #1 yelling loudly at night, while the environment was generally quiet during the day. Staff interviews confirmed awareness of the pattern of behavior. CNA #1, who worked both day and night shifts, reported that Resident #1 frequently yelled and screamed at intervals throughout the night and was generally quiet and often slept during the day, with staff assisting the resident out of bed into a geri-chair during both day and nighttime hours. The DON acknowledged the facility was aware of Resident #1’s increased nighttime yelling and extended daytime rest, attributing it to the resident’s Dementia and Psychosis, and stated that interventions such as monitoring, repositioning, offering care, and attempts at redirection had not stopped the behaviors. The Administrator also confirmed awareness of concerns that nighttime noise from Resident #1 affected other residents’ ability to rest. Despite this awareness and ongoing complaints from other residents, the disruptive nighttime yelling continued, resulting in a failure to uphold residents’ rights to a dignified existence and a comfortable environment.
Failure to Ensure Privacy and Dignified Care During Incontinence Care and Feeding
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were treated with dignity and provided privacy during care, as required by resident rights policies and skills checklists. The facility’s Nursing Facility Resident Rights policy guaranteed residents the right to be treated with dignity, courtesy, and respect, and to have privacy during personal care. Facility skills checklists for feeding and peri/incontinent care specified that staff should sit facing residents at eye level when feeding and provide privacy by drawing curtains and closing doors during incontinence care. For Resident #2, surveyors observed a CNA providing incontinent care without closing the resident’s room door and with the privacy curtain only partially drawn. From the surveyor’s position at the bottom right corner of the bed, it was possible to see into the hallway while the resident was uncovered and exposed. Resident #2’s records showed admission with diagnoses including epilepsy, infection of the skin and subcutaneous tissue, an open wound of the left upper arm, and gastrostomy status. A recent MDS assessment documented a BIMS score of 11, indicating moderate cognitive impairment, and that the resident was dependent for toilet hygiene. The CNA later confirmed awareness that incontinence care required provision of privacy and that she had been trained and competency-checked on this requirement. For Resident #3, surveyors observed a CNA assisting the resident with eating while standing over the resident rather than sitting beside her, contrary to the facility’s feeding skills checklist and training. The DON intervened during the observation and instructed the CNA that staff were to sit next to residents while assisting with eating. The CNA stated she had forgotten to sit beside the resident. Resident #3’s records showed recent admission with diagnoses of cerebral infarction (stroke), anemia, and hemiplegia and hemiparesis affecting the right dominant side, and a baseline care plan indicating the resident was dependent for eating. Other staff interviews, including with a CNA supervisor, an LPN, the DON, and the Administrator, confirmed that staff were trained at least monthly on residents’ rights, respectful and dignified care, provision of privacy during incontinence care, and the expectation that staff sit beside residents when assisting with eating.
Failure to Maintain Accessible Call Light for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was maintained within reach as required by the facility’s feeding skills checklist. The skills checklist for feeding a resident specifies that staff must leave the call light within the resident’s reach after feeding. For Resident #2, surveyors observed on two separate occasions that the call light was not accessible. On one observation, the resident was awake in bed with a lunch tray on the overbed table, and the call light was found lying on the floor under the head of the bed. The resident stated he could use his call light but did not know where it was. On a subsequent observation, Resident #2 was again in bed with a lunch tray in front of him, and the call light was hanging behind the mattress at the head of the bed, out of his sight and reach. The resident again stated he could use the call light but did not know where it was. Record review showed the resident had epilepsy, an infection of the skin and subcutaneous tissue, an open wound of the left upper arm, gastrostomy status, and a BIMS score of 11 indicating moderate cognitive impairment. Staff interviews with CNAs, an LPN, the DON, and the Administrator confirmed that call lights were expected to be within residents’ reach and answered timely, and that staff had received in-service training and competency checks on leaving call lights within reach. The Administrator also confirmed there was no specific written policy regarding call light placement.
Failure to Provide Required Perineal Cleansing During Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to provide incontinent care in accordance with its own peri-care policy and professional standards of practice for a male resident who was dependent for toilet hygiene. The facility’s written policy for peri/incontinent care for male residents, revised in January 2023, required cleansing of the perineal area starting at the urethra and working outward, including washing and rinsing the penis, scrotum, inner thighs, and perineal area front and back, followed by thorough drying. Record review showed the resident had diagnoses including epilepsy, infection of the skin and subcutaneous tissue, an open wound of the left upper arm, and gastrostomy status, and a Quarterly MDS with a BIMS score of 11 indicating moderate cognitive impairment, with the resident assessed as dependent for toilet hygiene. On the observed date and time, CNA #1 provided incontinent care to this resident by removing a wet urine-soaked brief, changing the fitted sheet, and applying a clean, dry brief without cleansing the resident’s perineal area, front or back, contrary to facility policy. During a subsequent interview, CNA #1 acknowledged she had received in-service training and competency check-offs on peri-care and knew she was supposed to cleanse the perineal area but did not do so, stating she was nervous. Additional interviews with CNA #2 (CNA supervisor and scheduler), an LPN, the DON, and the Administrator confirmed that staff were trained using the Peri Care–Incontinent Care Skills Checklist and that proper incontinent care includes cleansing the perineal area, front and back, in addition to changing the brief. The failure to perform the required cleansing during incontinent care constituted the cited deficiency related to prevention of urinary tract infections.
Failure to Maintain Infection Control Practices During PEG Tube and Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program by not maintaining aseptic technique and not providing ordered dressing changes for residents with PEG tubes and a sacral pressure injury. Facility policies on infection control and clean dressing changes required wound care to be provided in a manner that decreases the potential for infection and cross-contamination, including removal of soiled dressings with gloves, discarding gloves, performing hand hygiene, and donning clean gloves before continuing care. The peri-care audit tool also required glove removal, hand hygiene, and re-gloving after peri-care. These standards were not followed during multiple observed care episodes. For one resident with a PEG tube and diagnoses including Alzheimer’s disease, functional quadriplegia, and gastrostomy status, surveyors observed the PEG tube site without a dressing and with a yellowish-brown substance beneath and around the external skin disk extending about one-fourth inch onto surrounding skin. A CNA and an LPN both confirmed there was no dressing in place and acknowledged the drainage at the site. The LPN stated PEG tube site care should be completed daily and as needed for increased drainage and acknowledged that, with no dressing and the amount of drainage present, there was no way to tell when the site was last cleaned. Record review showed a physician order, effective several months prior, for daily cleansing of the PEG tube stoma with normal saline, patting dry, and applying a dry drain dressing to avoid skin breakdown. For another resident with severe protein-calorie malnutrition and gastrostomy status, the PEG tube site was observed with thick brown, crusted substance beneath the external skin disk extending approximately one-half to three-fourths of an inch to the surrounding area. The resident reported the site had not been cleaned in about three days and later stated they might have to clean it themselves. Follow-up observations confirmed the site remained unclean with visible drainage, and an LPN and the DON both confirmed the presence of thick, brown drainage and that the site had not been cleaned in several days, despite an order for daily cleansing with soap and water, rinsing, patting dry, and leaving open to air or applying a dry dressing if drainage was present. In a separate observation involving a resident with a stage IV sacral pressure ulcer and severe cognitive impairment, a CNA provided peri-care for stool soiling, then immediately assisted with wound care using the same gloves worn during peri-care, without performing hand hygiene or changing gloves. The CNA, treatment nurse, DON, and ADON all acknowledged that hand hygiene and glove change should have occurred between peri-care and wound care and that this represented an infection control concern.
Failure to Maintain Clean Resident Rooms and Shower Facilities
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by its Resident Rights & Quality of Life Policy. For one resident, surveyors observed a bag of odorous soiled linens resting on the floor of the room, and the resident’s bed was made with a bedspread that had a football-sized hole exposing the mattress. The resident, who was cognitively intact with a BIMS score of 14 and had Type 2 Diabetes Mellitus, reported that it was not unusual for bags of soiled linens to be left on the floor and for bedding to be damaged. A CNA confirmed that soiled linens were commonly left in bags on the floor after morning care and that torn bedding should not be used, and later placed the bag of soiled linens on the resident’s furniture where his clean clothing was hanging. The resident remained upset the following day, and a dead roach was observed under his bed near the headboard. Additional deficiencies were identified in other resident rooms. One resident with End Stage Renal Disease and a severely impaired cognition (BIMS score of 5) reported that housekeeping did not clean under the bed; surveyors observed three large dead roaches under the bed, which remained there the following day. When the Housekeeping Supervisor later observed the room, five dead roaches were present under the bed, and he stated the area should not have been in that condition. Another resident, with a diffuse traumatic brain injury and a moderately impaired cognition (BIMS score of 10), reported frequently picking up and disposing of dead roaches himself because staff did not remove them, and a large dead roach was observed under his bed. The facility also failed to maintain a clean and sanitary north shower room. During a Resident Council interview, multiple cognitively intact and moderately impaired residents reported refusing to use the shower room due to cleanliness concerns, including observations of dirty clothing, feces, and residue on shower chairs and floors. A housekeeper stated that while she cleaned the shower rooms multiple times a day, CNAs were responsible for cleaning and sanitizing the shower room after each use and that she had observed occasions when CNAs failed to do so. A subsequent observation of the north shower room revealed soiled clothing, including a soiled brief, on a shower chair, a yellow fluid-like substance on the floor and shower chair, and a white powdery substance on the floor, with no staff present. The Social Services Assistant, DON, and Administrator each acknowledged that staff were expected to clean and sanitize the shower room after each use.
Ongoing Roach Activity Demonstrates Ineffective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program as required by its pest control policy dated 9/1/2014, which states the center will maintain an ongoing program to keep the building free of insects and rodents. Surveyors observed multiple instances of roach and insect activity in resident rooms and common areas. In one cognitively intact resident’s room, gnats were seen flying and a dead roach was later found under the bed near the headboard. Another resident’s room contained three large dead roaches under the bed on two consecutive days; this resident reported that roaches were regularly seen in the room, especially at night, crawling on the ceiling and falling onto him and his roommate, and that staff had been notified but he had not seen staff respond to assess or treat the issue. A third resident reported seeing roaches on the ceiling and under the bed and stated he often removed dead roaches himself because staff did not; a large dead roach was observed under his bed. A family member of another resident reported feeling it was necessary to bring her own roach spray due to concerns about roaches in the resident’s room and stated she was told she could not keep the spray in the room, expressing concern that the roach problem needed to be addressed. During a Resident Council meeting, two large roaches were observed crawling across the floor, and residents reported that roaches were commonly seen in rooms and common areas, including on walls, ceilings, and floors, particularly at night. The contracted pest control provider reported he provides monthly services, focusing on different areas each visit, primarily treating entry points and exterior areas, and stated he had not personally observed roaches and received only occasional complaints. Facility leadership, including the housekeeping supervisor, DON, and Maintenance Director, described expectations that staff report pest sightings and that pest control services are available monthly and as needed, but the ongoing presence of roaches and dead insects in resident rooms and common areas demonstrated that the pest control program was not effectively preventing or controlling pests.
Failure to Ensure Resident Access to Private Telephone Communication
Penalty
Summary
The facility failed to ensure a resident’s right to reasonable access to and privacy in the use of a telephone for communication. Facility policy on Resident Rights, revised December 2016, states that residents are guaranteed access to a telephone, mail, and email, and the ability to communicate in person and by mail, email, and telephone with privacy. Resident #1 was admitted on 12/18/24 with diagnoses including Sjogren syndrome, rheumatoid arthritis, chronic kidney disease, and morbid obesity. During an interview, the resident reported that she had dropped and broken her personal cellular telephone, which she had used for private communication, and that the facility did not have any telephone that was convenient for her to use privately. She stated that no staff had offered her the use of a staff office or any other mechanism for private communication, and she was upset because she relied on telephone contact with her significant other, who had cancer and was unable to visit. Observations and staff interviews confirmed the lack of accessible, private telephone options for residents on South Hall. An observation on the 100 Hall revealed there was no cordless telephone available for resident use. The DON confirmed that the facility did not have a method to provide residents on South Hall with private communication without first making arrangements or an appointment to use a staff office, and that the cordless telephones in the facility did not have sufficient range to reach South Hall. The SSD confirmed there were no cordless telephones at the South Hall nurses’ station that could be taken to residents’ rooms and acknowledged that Resident #1’s cell phone had been broken and sent out for repair. The Administrator also confirmed that residents on South Hall did not have a method for private communication without prior arrangements and acknowledged that access to private communication is a guaranteed resident right.
Failure to Provide Adequate ADL Assistance for Personal Hygiene
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) to maintain personal hygiene for one resident who was dependent on staff for care. Facility policy on ADLs, revised March 2018, stated that residents unable to carry out ADLs independently would receive services necessary to maintain good grooming and personal and oral hygiene. Record review showed the resident was admitted with heart failure, chronic kidney disease, and hypertension, had a BIMS score of 12 indicating moderate cognitive impairment, was always incontinent of bowel and bladder, and required substantial/maximal assistance for personal hygiene and was dependent for toilet hygiene. A complainant reported that the resident had expressed difficulty getting staff to provide assistance with ADLs. During an observation and interview with the resident, accompanied by an LPN, the resident reported ongoing difficulty obtaining assistance with ADLs. The surveyor observed that the resident had ten long, dirty fingernails protruding 3.0 to 3.5 millimeters past the fingertips, with a black substance beneath all fingernails; the resident stated they needed cleaning and cutting and were too long. The LPN described the fingernails as too long and dirty, confirmed that nursing staff were responsible for checking fingernails daily during care and weekly during body audits, and acknowledged that staff were responsible for providing fingernail care as part of ADLs. The LPN also confirmed that long, dirty, unkempt fingernails had the potential to cause damage or scratches to the resident’s skin. The DON stated she was not aware of any complaints from the resident but confirmed her expectation that ADLs for residents dependent on staff for personal hygiene would be maintained and provided as needed, and that licensed nurses trimmed fingernails for some residents while any nursing staff could clean under fingernails. The Administrator confirmed that personal hygiene and grooming were part of resident ADLs and were expected to be provided for all dependent residents.
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