Brandon Community Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Brandon, Mississippi.
- Location
- 355 Crossgate Blvd, Brandon, Mississippi 39042
- CMS Provider Number
- 255106
- Inspections on file
- 32
- Latest survey
- January 12, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Brandon Community Care Center during CMS and state inspections, most recent first.
A resident with Alzheimer’s disease, unsteadiness on feet, and documented memory problems fell and sustained multiple head and facial injuries after a housekeeper mopped the resident’s room floor without placing wet floor signage. The housekeeper, working on the unit for the first time, assumed the resident was bedridden and would not get up, and reported that no wet floor signs were available. Shortly after the room was mopped, staff heard the resident crying and found the resident lying face down on a wet floor in a pool of blood, with no caution sign present. Clinical documentation and hospital records noted lacerations to the head and face, periorbital discoloration, an acute orbital blowout fracture, and suspected concussion. Interviews with the DON, CNA, LPN, and administrator confirmed that the floor was wet from recent mopping, no wet floor sign had been placed, and staff had not identified the wet floor as a hazard before the incident.
A resident with a history of mental health diagnoses began exhibiting new exit-seeking behaviors, such as packing belongings and waiting at the front door, but staff did not update her care plan or implement additional supervision. The resident exited the facility unnoticed and was found in a staff member's car in the parking lot after about fifteen minutes. No incident report was completed, and no missing resident protocol was initiated, despite the facility's policy requiring intervention for such behaviors.
A resident with a history of mental health disorders exited the facility unsupervised and was found in a staff member's car in the parking lot after being missing for about fifteen minutes. The event was not documented as an elopement, no incident report was completed, and required notifications to authorities were not made, despite facility policy and staff awareness of the incident.
A resident with multiple psychiatric diagnoses exited the facility unsupervised and was found in a staff member's car in the parking lot. Staff failed to initiate missing resident procedures, did not complete an incident report, and did not conduct a thorough investigation or notify the State Agency, despite facility policy requiring immediate action for such incidents.
Two residents did not have comprehensive care plans developed or updated to address significant changes in their conditions. One resident exhibited new wandering and exit-seeking behaviors that were documented by staff but not reflected in the care plan, resulting in an unsupervised elopement. Another resident was admitted with a nephrostomy tube, but the care plan did not include any instructions or interventions for its management, and staff were not provided with formal guidance. Facility policies requiring timely and person-centered care plan updates were not followed.
A resident with a history of mental health conditions and recent wandering and exit-seeking behaviors exited the facility unnoticed and was found unsupervised in a staff member's car in the parking lot. Despite clear behavioral changes, staff did not update the care plan, implement elopement precautions, or follow facility protocols, resulting in a failure to provide adequate supervision and a secure environment.
A resident with a nephrostomy tube did not receive or have documented any dressing changes or tube flushes during their stay. Nursing staff did not perform routine maintenance due to the absence of physician orders or care plan instructions, and the DON and Medical Director confirmed that required care and documentation were not provided, resulting in a failure to meet professional standards.
A resident with diabetes and end stage renal disease did not receive daily skin and foot assessments as required by their care plan. Staff failed to identify or document developing foot wounds, which were first discovered and treated at a dialysis center. Despite notification from the dialysis center, facility staff did not assess or treat the wounds for several days, and the wound care team was not consulted until later.
A resident with end-stage renal disease and severe cognitive impairment developed wounds on the right foot that were identified and treated by dialysis staff, who notified facility staff of the need for follow-up. Despite this, facility staff did not assess or treat the wounds for several days, failed to document the issue, and did not notify the physician or wound care team, resulting in a delay in care and lack of appropriate interventions.
A resident with cognitive impairment and dependence on hemodialysis did not have a pressure dressing removed from a dialysis access site within the time frame specified by the care plan and physician's order. Staff interviews and record reviews confirmed that the care plan was not followed, resulting in the dressing remaining in place longer than directed.
A resident dependent on renal dialysis did not have a pressure dressing removed from their access site within the required timeframe, despite clear physician orders and instructions from the dialysis unit. The dressing remained in place overnight, and the resident, who was visually impaired, was unable to remove it independently. Staff and administration confirmed the failure to follow orders and instructions for timely dressing removal.
Two residents did not have complete or properly implemented care plans: one with an indwelling urinary catheter lacked a care plan addressing catheter care and privacy, resulting in the catheter bag being left uncovered in public areas, while another dependent resident did not consistently receive scheduled showers due to discrepancies between the care plan and staff scheduling. Staff interviews confirmed lack of awareness and communication regarding these care needs.
A resident with multiple urinary diagnoses had an indwelling Foley catheter in place without a documented physician order, contrary to facility policy. Staff, including an LPN and the MDS nurse, were unaware of the need for a catheter order or the presence of the catheter, and the DON and Administrator confirmed the lack of compliance with professional standards of care.
A resident with severe cognitive impairment and multiple medical conditions was observed in a common area with an uncovered urinary catheter bag containing visible urine. Multiple staff, including an LPN and the MDS Nurse, were unaware of the need for a catheter bag cover, resulting in a failure to maintain the resident's privacy and dignity as required by facility policy.
Two residents did not receive necessary hygiene and grooming care as required by facility policy. One resident had facial hair that interfered with eating and was not trimmed despite expressing discomfort, while another dependent resident did not receive scheduled showers for at least two weeks, even though appropriate equipment was available. Staff interviews revealed inconsistencies in care delivery and scheduling.
The facility failed to maintain a safe and sanitary environment, affecting multiple residents. Observations revealed cluttered and dirty rooms, with dried spots on equipment and furniture, and the presence of pests. Interviews with staff highlighted issues with housekeeping and maintenance, contributing to the unsanitary conditions.
A resident with severe cognitive impairment and incontinence was not provided timely care, remaining in wet briefs for over three hours. Facility policy required checks every two hours, but staff failed to adhere to this, with the CNA leaving without making rounds and the subsequent CNA not checking the resident until later. The LPN and DON confirmed the delay and acknowledged the impact of staffing issues on care.
A facility failed to provide care to a resident with a feeding tube according to medical orders. The resident's enteral feeding pump was turned off for over four hours, despite orders to hold feeding for only 30 minutes before meals. The LPN expressed confusion about the orders, and the DON confirmed the feeding should not have been held for so long, potentially affecting the resident's nutritional needs.
The facility experienced staffing shortages on multiple days, leading to inadequate care for residents. Staff interviews and record reviews revealed that CNAs were often overburdened, resulting in delayed care. The Staff Development Director did not use the Facility Assessment Tool for scheduling, relying instead on census numbers. A resident reported long wait times for assistance, and CNAs were sometimes reassigned to non-care duties, further impacting care quality.
The facility failed to ensure a clean and homelike environment, as observed in the rooms of two residents, a shower room, and a hallway. A resident's room was found dirty with trash and dust, while another resident's room had a strong urine odor due to incontinence issues. The shower room had stains on the floor, and the hallway had dusty decorative items and dirty hand sanitizer dispensers. The Housekeeping Supervisor and Administrator acknowledged the issues, citing staffing challenges.
The facility failed to ensure proper food storage and labeling in the walk-in refrigerator and freezer. Unlabeled and undated containers with unknown substances were found, and food was stored on the floor. The Dietary Manager, responsible for these tasks, had been out sick and decided not to return. The facility received a C rating from a recent MSDH inspection.
A resident with severe cognitive impairment and multiple diagnoses refused medications for several days without the attending physician or responsible party being consistently notified, contrary to the facility's policy. The Pharmacy Consultant, Physician, and Nurse Practitioner were unaware of the extent of the refusals, and the facility lacked a system to address the issue.
The facility failed to maintain a clean, homelike environment by not ensuring clean linen was available for two residents. One resident had to sit in a chair due to the lack of clean sheets, while another was found without a fitted sheet on the mattress. Staff interviews revealed that linen was available, but staff were either unaware of its location or used the lack of linen as an excuse not to change beds.
A facility failed to maintain a medication error rate below 5%, resulting in a 12.12% error rate. An LPN administered medications via a PEG tube instead of by mouth as per physician's orders. The DON confirmed the error upon review.
The facility failed to serve food in a manner that was appealing and palatable for two residents. One resident, with Type 2 Diabetes Mellitus and Iron Deficiency Anemia, stated the food tasted like slop. Another resident, with diagnoses including Orthopedic Aftercare and Hypertension, complained the food tasted bad. A lunch tray tested with the Dietician revealed bland vegetables, and the Dietician acknowledged the issue. The second resident ate only 50% of the lunch meal and preferred fresh fruits and vegetables.
The facility failed to ensure that residents who smoked were allowed to exercise their right to smoke during designated times. Two residents reported not receiving scheduled smoking breaks and observed staff idling instead of assisting them. Interviews with staff confirmed the issue, and the Director of Nursing acknowledged the negative impact on residents' feelings.
A resident with severe cognitive impairment and multiple diagnoses reported not receiving scheduled showers, leading to discomfort and complaints. Despite a grievance filed by the resident's daughter and an interdisciplinary team meeting, the issue remained unresolved due to inconsistent care and poor communication among staff.
A resident dependent on staff for ADLs and incontinent care was left soiled for extended periods, especially during the night shift. Despite complaints from the resident and her daughter, staff failed to provide timely care, leading to the resident using a pillowcase to absorb urine. Observations and interviews confirmed the deficiency in care practices.
Failure to Prevent Fall After Room Was Mopped Without Wet Floor Signage
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment as free as possible from accident hazards and to provide adequate supervision and assistance to prevent accidents, resulting in a resident fall with injury. Facility policies titled “Safety and Supervision of Residents” and “Homelike Environment” state that resident safety, supervision, and a safe environment are priorities. Despite these policies, a housekeeper entered a resident’s room at approximately 10:30 AM, found the resident asleep, and proceeded to clean and mop the floor without placing any wet floor signage. The housekeeper reported believing the resident was bedridden and did not expect the resident to get up unassisted, and also stated that no wet floor signs were available and that it was their first time working on the unit. Progress notes and witness statements document that shortly after the room was mopped, staff heard the resident crying and found her lying face down on the wet floor in a pool of blood, with no wet floor sign in place. The resident sustained multiple injuries, including a 2 cm laceration to the top of the head, a 0.75 cm laceration to the forehead, a 0.25 cm laceration on the bridge of the nose, discoloration and contusions around both eyes, and discoloration to the left knee. A Family Nurse Practitioner documented that the resident was seen on the floor with blood pooled around her head and lacerations to the forehead and nose, with a contusion forming over the left eye. Hospital records further documented facial trauma, an orbital fracture, and suspected concussion, with suturing required for the laceration and imaging confirming an acute orbital blowout fracture of the left orbital floor. Interviews with staff confirmed that the floor was wet from recent mopping and that no caution signage had been placed. The Director of Nursing stated that the resident was last seen around 10:55 AM and was found around 11:00 AM lying face down on the wet floor, confirming that the housekeeper had assumed the resident was not mobile. A CNA reported having assisted the resident with a shower and returning her to her room, where the resident was sitting up watching television prior to the incident, and later found the resident on the wet floor with no sign present. An LPN described entering the room after hearing the resident crying, stumbling on the wet floor, and finding the resident face down with blood on her face and hair. The Licensed Nursing Home Administrator confirmed that the housekeeper mopped the floor without posting a wet floor sign and that staff did not identify the wet floor as a potential hazard prior to the incident. Record review showed the resident had Alzheimer’s disease, unsteadiness on feet, and documented memory problems with some difficulty in new situations, indicating known cognitive and mobility issues at the time of the fall.
Failure to Prevent Resident Elopement Due to Lack of Timely Intervention
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect by not implementing measures to prevent elopement for a resident who had recently begun exhibiting exit-seeking behaviors. The resident, who had diagnoses including bipolar disorder, anxiety disorder, schizophrenia, and major depressive disorder, began displaying new behaviors such as packing belongings and waiting at the front door, believing her family was coming to get her. Despite these documented behaviors, staff did not update the resident's care plan or implement additional supervision or wander management interventions prior to the incident. On the day of the incident, the resident exited the facility unnoticed and unsupervised. She was found approximately fifteen minutes later by a CNA, sitting in the passenger seat of the CNA's car in the facility parking lot, which was located near a busy four-lane boulevard. Staff were unaware of the resident's absence until she was brought back inside. There was no incident report completed at the time, and no head count or missing resident protocol was initiated following the event. Interviews with staff confirmed that the resident's care plan had not been updated to reflect her new exit-seeking behaviors, and that elopement drills or additional supervision had not been implemented. The facility's policy required identification and intervention in situations where neglect was more likely to occur, including increased supervision for residents at risk. However, despite multiple staff members observing and documenting the resident's exit-seeking behaviors in the days leading up to the incident, no changes were made to her care plan or supervision level. The lack of timely intervention and failure to follow facility policy resulted in the resident being able to leave the facility unsupervised, placing her at risk.
Removal Plan
- The President in-serviced the Social Services Department on ensuring that care plans and interventions are implemented for residents with behavioral changes that verbalize leaving the facility, exit seeking, wandering, and packing belongings should be immediately assessed and elopement precautions implemented.
- The Executive Director notified the Mississippi Department of Health of the incident regarding Resident #1 exiting the facility unaccompanied and unnoticed by staff.
- An audit was completed for all residents who were determined to be at risk for elopement to ensure accuracy of the care plan and appropriate interventions by the Director of Nurses.
- A sign was placed on all exit doors reminding staff and visitors to be cautious when entering and exiting the facility in an effort to prevent residents from leaving the facility without staff knowledge.
- The Executive Director and Director of Nurses reinterviewed Resident #1 to confirm details of the elopement.
- Letters were mailed to family members by Social Services as a reminder to use precautions when entering and exiting the facility and to notify staff if a resident verbalizes thoughts of leaving the facility.
- The Receptionist who vacated the front desk was in-serviced by the Executive Director to ensure that coverage is requested by another staff member prior to leaving the front desk. All routine staff who cover the receptionist area were also in-serviced.
- A 100% audit of elopement binders was conducted by the Social Service Department to ensure the binders' information was reflective of all residents who are deemed as elopement risk.
- An Emergency Quality Assurance Committee was held with key facility leadership and the Medical Director to review the incident and corrective actions.
Failure to Report Elopement and Neglect Incident to Authorities
Penalty
Summary
The facility failed to ensure that an allegation of neglect and an incident of elopement involving one resident were reported to the appropriate agencies, including the State Agency, as required by state and federal law. On the date of the incident, a resident with a history of bipolar disorder, anxiety disorder, schizophrenia, and major depressive disorder, who had recently exhibited new exit-seeking behaviors, exited the facility unnoticed and unsupervised. The resident was missing for approximately fifteen minutes before being found by a CNA sitting in the passenger seat of the CNA's car in the facility parking lot, which was located near a busy four-lane boulevard with no barrier or crosswalk. The resident was then escorted back into the facility. Facility records, including the accident/incident log and progress notes, showed that the event was not documented as an elopement, and no incident report was completed. The progress notes indicated that the Unit Manager, DON, Social Worker, and Executive Director were notified of the incident. However, the Executive Director determined that the event was not an elopement because the resident stated she was waiting for her brother, despite the facility's policy requiring anyone taking a resident out to sign them out at the nurses' station. No one had signed the resident out or made arrangements for her to leave, and the resident had exited the building with a group of nursing students without staff knowledge. Interviews with staff confirmed that the incident was not reported to the State Agency or other required authorities at the time. The Executive Director, DON, and Receptionist all acknowledged awareness of the incident but did not initiate the required reporting procedures. The facility's policies on abuse prevention, missing residents/elopements, and investigation and reporting of violations all require immediate reporting of such incidents to the appropriate authorities, which was not followed in this case.
Removal Plan
- The President in-serviced the Social Services Department on ensuring that care plans and interventions are implemented for Residents with behavioral changes that verbalizing to leave the facility, exit seeking, wandering and packing belongs should be immediately assessed and elopement precautions implemented.
- The Executive Director notified the Mississippi Department of Health of the incident regarding Resident #1 exiting the facility unaccompanied and unnoticed by staff.
- An audit was completed for all Residents who were determined to be at risk for elopement risk to ensure accuracy of the care plan and appropriate interventions by the Director of Nurses.
- A sign was placed on all exit doors reminding staff and visitors to be cautious when entering and exiting the facility in an effort to prevent Residents from leaving the facility without staff knowledge.
- The Executive Director and Director of Nurses reinterviewed Resident#1. Resident#1 confirmed that she exited the facility from the front door by following other people out. Resident #1 could not recall how many people she followed or give a description.
- Letters were mailed to family members by Social Services as a reminder to use precautions when entering and the facility in an effort to prevent Residents from exiting the facility unaccompanied or unnoticed by staff. The letter also requested that family members notify the staff of the facility if a Resident verbalizes thoughts of the leaving the facility.
- The Receptionist who vacated the front desk was in-serviced by the Executive Director to ensure that coverage is requested by another staff member prior to leaving the front desk. In addition to all routine staff who the receptionist area was in-serviced by the Executive Director.
- 100% audit of elopement binders were conducted by the Social Service Department to ensure the binders information was reflective of all Residents who are deemed as elopement risk.
- An Emergency Quality Assurance Committee was held with the following staff in attendance: President, Executive Director, Regional Director of Clinical Services, Director of Nurses, Assistant Executive Directors, Social Service Director, Social vice Assistants and Medical Director. The IP nurse was present by phone.
Failure to Investigate and Report Resident Elopement
Penalty
Summary
The facility failed to initiate a thorough investigation into an allegation of neglect and an incident of elopement involving one of six sampled residents. On the specified date, a resident exited the facility unsupervised and was found sitting in a staff member's car in the facility parking lot. The resident had left the building unnoticed by staff during a shift change and was able to access an area adjacent to a busy four-lane boulevard. The staff member who discovered the resident escorted her back into the facility and notified the appropriate personnel, including the Executive Director and the Director of Nursing Services. Despite the incident, there was no documentation of the elopement in the facility's accident/incident log, and no incident report was completed. Multiple staff members, including LPNs and the Unit Manager, confirmed that they were aware of the resident's unsupervised exit but did not participate in any investigation or initiate missing resident procedures. No head count of residents was conducted, and the event was not reported to the State Agency as required. The Executive Director stated that the incident was not considered an elopement because the resident claimed she was waiting for her brother, and therefore, no report was made to any agencies. The resident involved had a history of bipolar disorder, anxiety disorder, schizophrenia, and major depressive disorder, but her most recent assessment indicated no cognitive impairment and no documented wandering or exit-seeking behaviors. The facility's policies required immediate investigation and reporting of such incidents, but these procedures were not followed. The failure to conduct a thorough investigation and report the incident placed the resident and others at risk, as identified by the State Agency, which cited the facility for failing to meet regulatory requirements regarding the investigation and prevention of alleged violations.
Removal Plan
- The President in-serviced the Social Services Department on ensuring that care plans and interventions are implemented for Residents with behavioral changes that verbalizing to leave the facility, exit seeking, wandering and packing belongs should be immediately assessed and elopement precautions implemented.
- The Executive Director notified the Mississippi Department of Health of the incident regarding Resident #1 exiting the facility unaccompanied and unnoticed by staff.
- An audit was completed for all Residents who were determined to be at risk for elopement risk to ensure accuracy of the care plan and appropriate interventions by the Director of Nurses.
- A sign was placed on all exit doors reminding staff and visitors to be cautious when entering and exiting the facility in an effort to prevent Residents from leaving the facility without staff knowledge.
- The Executive Director and Director of Nurses reinterviewed Resident#1. Resident#1 confirmed that she exited the facility from the front door by following other people out. Resident #1 could not recall how many people she followed or give a description.
- Letters were mailed to family members by Social Services as a reminder to use precautions when entering and the facility in an effort to prevent Residents from exiting the facility unaccompanied or unnoticed by staff. The letter also requested that family members notify the staff of the facility if a Resident verbalizes thoughts of the leaving the facility.
- The Receptionist who vacated the front desk was in-serviced by the Executive Director to ensure that coverage is requested by another staff member prior to leaving the front desk. In addition to all routine staff who cover the receptionist area, the receptionist was in-serviced by the Executive Director.
- 100% audit of elopement binders were conducted by the Social Service Department to ensure the binders information was reflective of all Residents who are deemed as elopement risk.
- An Emergency Quality Assurance Committee was held with the following staff in attendance: President, Executive Director, Regional Director of Clinical Services, Director of Nurses, Assistant Executive Directors, Social Service Director, Social Service Assistants and Medical Director. The IP nurse was present by phone.
Failure to Develop and Implement Comprehensive Care Plans for Residents with Behavioral and Medical Needs
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, resulting in significant deficiencies. For one resident with a history of bipolar disorder, anxiety disorder, schizophrenia, and major depressive disorder, new wandering and exit-seeking behaviors were documented for at least a week prior to an incident where the resident eloped from the facility unnoticed and was outside unsupervised for approximately fifteen minutes. Despite staff observations and documentation of these behaviors, including packing belongings and attempting to leave, the care plan was not updated to address elopement or wandering risk. Progress notes indicated that interventions such as one-on-one observation and the application of a wander management device were initiated only after the elopement occurred, but these were not reflected in the resident's care plan. Multiple staff interviews confirmed that the care plan was not updated in response to the resident's behavioral changes, and the interdisciplinary team did not coordinate to ensure the care plan addressed the new risks. Another resident was admitted with a nephrostomy tube for urinary drainage due to obstructive uropathy. The hospital discharge summary and admission nursing assessment noted the presence of the nephrostomy tube, but the initial and comprehensive care plans did not include any focus, goals, or interventions related to nephrostomy tube care. There were no instructions for site care, flushing, dressing changes, or infection prevention, and the facility did not contact the physician or specialist for guidance on nephrostomy care upon admission. Staff interviews revealed that nursing staff relied on general practice rather than formal guidance, and the MDS Coordinator acknowledged that the absence of a care plan for the nephrostomy tube was an oversight. The DON and Medical Director both confirmed that the lack of a care plan for this specialized medical device was a failure in the care planning process and could result in missed or inconsistent care. The facility's policies required that care plans be person-centered, updated upon changes in condition, and include measurable goals and staff approaches for each identified problem or need. However, in both cases, the facility did not follow its own policies or regulatory requirements to ensure that care plans were comprehensive and updated in response to significant changes in residents' conditions or care needs. This failure led to a lack of clear instructions for staff and placed residents at risk for inadequate supervision and care.
Removal Plan
- The President in-serviced the Social Services Department on ensuring that care plans and interventions are implemented for Residents with behavioral changes that verbalizing to leave the facility, exit seeking, wandering and packing belongs should be immediately assessed and elopement precautions implemented.
- The Executive Director notified the Mississippi Department of Health of the incident regarding Resident # 1 exiting the facility unaccompanied and unnoticed by staff.
- An audit was completed for all Residents who were determined to be at risk for elopement risk to ensure accuracy of the care plan and appropriate interventions by the Director of Nurses.
- A sign was placed on all exit doors reminding staff and visitors to be cautious when entering and exiting the facility in an effort to prevent Residents from leaving the facility without staff knowledge.
- The Executive Director and Director of Nurses reinterviewed Resident# 1. Resident# 1 confirmed that she exited the facility from the front door by following other people out. Resident #1 could not recall how many people she followed or give a decription.
- Letters were mailed to family members by Social Services as a reminder to use precautions when entering and the facility in an effort to prevent Residents from exiting the facility unaccompanied or unnoticed by staff. The letter also requested that family members notify the staff of the facility if a Resident verbalizes thoughts of the leaving the facility.
- The Receptionist who vacated the front desk was in-serviced by the Executive Director to ensure that coverage is requested by another staff member prior to leaving the front desk. In addition to all routine staff who the receptionist area was in-serviced by the Executive Director.
- 100% audit of elopement binders were conducted by the Social Service Department to ensure the binders information was reflective of all Residents who are deemed as elopement risk.
- An Emergency Quality Assurance Committee was held with the following staff in attendance: President, Executive Director, Regional Director of Clincial Services, Director of Nurses, Assistant Executive Directors, Social Service Director, Social vice Assistants and Medical Director. The IP nurse was present by phone.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Risk Identification
Penalty
Summary
The facility failed to provide adequate supervision and a secure environment to prevent the elopement of a resident who had documented new wandering and exit-seeking behaviors for at least a week. The resident, who had diagnoses including bipolar disorder, anxiety, schizophrenia, a history of falls, and was assessed as at risk for falls and requiring supervision for walking, exited the facility unnoticed and was found sitting unsupervised in a staff member's car in the parking lot. The resident had been observed packing belongings, expressing confusion, and making statements about leaving, but these behaviors were not identified as exit-seeking or elopement risk by staff. Despite multiple staff members observing the resident's behavioral changes, including repeated trips to the front entrance and packing bags, the care plan was not updated to reflect the new risk, and no interventions such as wander management devices or increased supervision were implemented prior to the elopement. Documentation of the resident's change in behavior was reported to the primary healthcare provider, who ordered a urinalysis, but the facility did not recognize or address the increased risk of elopement. Staff interviews revealed a lack of awareness and action regarding the resident's behaviors, and no incident report was completed after the resident exited the facility. Additionally, facility policies and procedures were not followed, as evidenced by the absence of an updated care plan, missing elopement binders at the nurses' station, and lack of head counts or elopement drills following the incident. The front entrance could be opened with a code, and the receptionist, who was aware of the resident's behaviors, left the desk unattended without ensuring coverage. The facility did not report the incident to the State Agency in a timely manner, and there was no thorough investigation or immediate implementation of elopement precautions for the resident prior to the event.
Removal Plan
- The President in-serviced the Social Services Department on ensuring that care plans and interventions are implemented for Residents with behavioral changes that verbalizing to leave the facility, exit seeking, wandering and packing belongs should be immediately assessed and elopement precautions implemented.
- The Executive Director notified the Mississippi Department of Health of the incident regarding Resident #1 exiting the facility unaccompanied and unnoticed by staff.
- An audit was completed for all Residents who were determined to be at risk for elopement risk to ensure accuracy of the care plan and appropriate interventions by the Director of Nurses.
- A sign was placed on all exit doors reminding staff and visitors to be cautious when entering and exiting the facility in an effort to prevent Residents from leaving the facility without staff knowledge.
- The Executive Director and Director of Nurses reinterviewed Resident#1. Resident#1 confirmed that she exited the facility from the front door by following other people out. Resident #1 could not recall how many people she followed or give a description.
- Letters were mailed to family members by Social Services as a reminder to use precautions when entering and the facility in an effort to prevent Residents from exiting the facility unaccompanied or unnoticed by staff. The letter also requested that family members notify the staff of the facility if a Resident verbalizes thoughts of the leaving the facility.
- The Receptionist who vacated the front desk was in-serviced by the Executive Director to ensure that coverage is requested by another staff member prior to leaving the front desk. In addition to all routine staff who the receptionist area was in-serviced by the Executive Director.
- 100% audit of elopement binders were conducted by the Social Service Department to ensure the binders information was reflective of all Residents who are deemed as elopement risk.
- An Emergency Quality Assurance Committee was held with the following staff in attendance: President, Executive Director, Regional Director of Clinical Services, Director of Nurses, Assistant Executive Directors, Social Service Director, Social vice Assistants and Medical Director. The IP nurse was present by phone.
Failure to Provide and Document Nephrostomy Tube Care
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with a nephrostomy tube. Upon admission, the resident had a urinary obstruction requiring a nephrostomy tube, as documented in hospital discharge records and admission notes. However, there were no physician orders for nephrostomy tube care, such as flushing or dressing changes, and no care plan was developed to address the device. Throughout the resident's stay, there was no documentation of any nephrostomy tube dressing changes or flushes in the clinical record, and nursing notes did not indicate that these essential care tasks were performed. Interviews with nursing staff revealed that neither the RN nor the LPN responsible for the resident's care had performed or documented dressing changes or tube flushes. The RN stated she had not received specific orders or a schedule for nephrostomy tube care and assumed another provider was managing it. The LPN confirmed she only visually monitored the site and did not perform routine maintenance, as there were no care plan instructions or physician orders. Both staff members acknowledged that routine care should have been in place and documented, but it was not. The Director of Nursing confirmed that the facility's standard practice requires physician orders and regular care routines for invasive devices, including scheduled dressing changes and tube flushes, with documentation for each instance. Upon review, the DON acknowledged the absence of orders and documentation for nephrostomy care and described this as a failure in care. The Medical Director also stated that nephrostomy tubes require routine care and monitoring, and expected nursing staff to proactively obtain necessary orders and provide care. The lack of documentation and care for the nephrostomy tube was confirmed as a failure to follow professional standards of practice.
Failure to Implement Care Plan for Daily Skin and Foot Assessments
Penalty
Summary
Facility staff failed to implement care plan interventions for a resident with diabetes mellitus and end stage renal disease, specifically neglecting daily skin and foot assessments as required by the resident's care plan. The care plan included interventions to check the resident's body for skin breaks and to inspect feet daily for open areas, sores, pressure areas, blisters, edema, or redness. Despite these directives, staff did not identify or document developing wounds on the resident's right foot. The wounds were first discovered and treated at an outside dialysis center, where significant skin breakdown and discoloration were noted, and the facility was notified of the findings. Upon the resident's return from dialysis, facility staff completed a weekly skin assessment but failed to document the wounds or the dressing applied by the dialysis center. The LPN responsible for the assessment could not confirm whether the skin check was actually performed. The wound care physician and wound care nurse were not consulted or made aware of the wounds until several days later, and the wounds remained untreated by facility staff for five days after being discovered by the dialysis center. Interviews with facility leadership confirmed that staff did not follow the care plan or respond appropriately to the external notification of the resident's condition.
Failure to Provide Timely Wound Care Following Notification from Dialysis Clinic
Penalty
Summary
Facility staff failed to provide necessary care and services and did not respond appropriately to changes in a resident's condition when wounds were identified and treated by a dialysis clinic. The dialysis staff discovered wounds on the resident's right foot, including missing skin and black discoloration, and notified the facility on the same day. Despite this notification, the facility did not assess or initiate treatment for the wounds until five days later. The resident reported that only the dialysis staff had changed his dressing, and no one from the facility had checked or treated the wounds during this period. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's foot wounds. The unit manager and wound care nurse were unaware of any issues, and there was no evidence in the 24-hour nursing reports or electronic medical record that the physician had been notified or that any interventions had been implemented. The facility's policies required weekly skin audits and prompt intervention for identified skin conditions, but the weekly skin assessment completed after the resident returned from dialysis did not document the wounds, and the wound care nurse could not confirm if the assessment had actually been performed. The resident had a history of end-stage renal disease and severe cognitive impairment. Observations at the dialysis center confirmed that the same dressing applied by dialysis staff remained unchanged for several days, and the facility's wound care physician did not receive a consultation order until five days after the initial notification. Facility leadership acknowledged that staff failed to ensure appropriate wound care, monitoring, and follow-up actions, despite being informed of the resident's condition by the dialysis clinic.
Failure to Follow Care Plan for Dialysis Access Site Dressing Removal
Penalty
Summary
The facility failed to implement a comprehensive care plan intervention for a resident who receives hemodialysis, specifically regarding the timely removal of a pressure dressing from the resident's dialysis access site. The care plan, dated 10/15/24, required that the pressure dressing be removed four hours post-dialysis unless otherwise specified, and the physician's order directed removal six hours after returning from dialysis. However, during an observation on 04/01/25, the resident was found to still have the bandage in place from a dialysis treatment that occurred the previous day, indicating the dressing had not been removed as required. Interviews with facility staff, including the Unit Manager, DON, and LPNs, confirmed that the care plan and physician's orders were not followed. The DON and LPNs acknowledged the failure to remove the bandage and to consult the care plan for guidance. The resident involved had a history of dependence on renal dialysis and was cognitively impaired, with a BIMS score of 6. The deficiency was identified through observation, record review, and staff interviews, all of which confirmed the lapse in following the established care plan and physician's orders.
Failure to Timely Remove Dialysis Access Site Dressing
Penalty
Summary
Facility staff failed to ensure the timely removal of a pressure dressing from a dialysis access site for a resident dependent on renal dialysis. The resident had a physician's order and specific instructions from the dialysis unit to remove the pressure dressing within four to six hours after returning from dialysis. Documentation on the Dialysis Information Update Transfer Form repeatedly indicated the required timeframe for dressing removal. Despite these clear instructions, the dressing remained in place well beyond the specified period, as confirmed by observation and staff interviews. The resident, who was visually impaired and unable to remove the dressing independently, reported notifying nursing staff to remove the bandage, but it was not done. The dialysis nurse stated that she had previously educated facility staff, including the DON and Administrator, about the importance of timely dressing removal. Both the DON and Administrator acknowledged that staff failed to follow the physician's order and dialysis instructions, and neither was aware that this was a recurring issue until it was brought to their attention.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, resulting in unmet care needs. For one resident with a history of bladder incontinence and an indwelling urinary catheter, the care plan did not address catheter care or include interventions related to the presence of the catheter. Observations confirmed that the resident's urine collection bag was left uncovered in a public area, and multiple staff members, including the MDS Nurse and Unit Manager, were unaware of the catheter's presence or the need for a care plan addressing catheter care and privacy measures. Another resident, who was dependent on staff for activities of daily living due to dementia, did not consistently receive scheduled showers as outlined in the care plan. The care plan specified assistance with showers three times weekly, but the resident reported not receiving showers on scheduled days and expressed dissatisfaction with having to request them. Staff interviews revealed confusion regarding the resident's shower schedule, and the CNA assigned to the resident was unable to confirm when the last shower was provided. The MDS Nurse acknowledged that care plans are developed and updated by nursing staff and that instructions are made available to CNAs through the facility's computer system. However, discrepancies between the care plan and the weekly shower list contributed to missed care. The Director of Nursing and Administrator confirmed the lack of a catheter care plan for the first resident and acknowledged the inconsistency in shower scheduling for the second resident.
Failure to Obtain Physician Order for Indwelling Catheter
Penalty
Summary
A deficiency was identified when a resident with chronic kidney disease, neuromuscular dysfunction of the bladder, and prostatic hyperplasia was found to have an indwelling Foley catheter in place without a corresponding physician order documented in the medical record. The resident had been admitted with the catheter in place, and staff interviews confirmed that the catheter had remained since admission. Despite facility policy requiring all physician orders to be written and signed, there was no order for the catheter itself, only an order for catheter care that was initiated after the resident had already been in the facility for an extended period. Observations revealed the resident seated in a wheelchair with an uncovered urine collection bag, and staff, including an LPN and the MDS nurse, were unaware of the need for a catheter order or the presence of the catheter. The DON and Administrator both confirmed that care should be provided according to physician orders and that the lack of a documented order for the catheter did not meet professional standards of care. The deficiency was further supported by the absence of a physician order in the resident's record and staff's lack of awareness regarding catheter care and monitoring.
Resident Dignity Compromised by Uncovered Urinary Catheter Bag
Penalty
Summary
A deficiency occurred when a resident's urinary catheter bag was left uncovered and visible in a public common area, specifically the Unit 2 Dining Room, with approximately eighty milliliters of urine visible. Multiple observations confirmed that the catheter bag was not covered, and this was witnessed by both facility staff and the survey team. The facility's policy on resident rights, which emphasizes privacy and dignity, was not followed in this instance. Interviews with staff revealed a lack of awareness and monitoring regarding the resident's catheter care. The LPN assigned to the resident was new to the facility and unaware of the need for a catheter bag cover. The MDS Nurse was also unaware that the resident had a catheter until it was pointed out during the survey. The Unit 2 Manager confirmed that the resident had an indwelling catheter since admission. The resident in question had severe cognitive impairment and diagnoses including chronic kidney disease, neuromuscular dysfunction of the bladder, and prostatic hyperplasia.
Failure to Provide Required Hygiene and Grooming Care
Penalty
Summary
The facility failed to provide necessary care for hygiene, bathing, and grooming for two of eight sampled residents. One resident was observed with a long mustache and beard, with facial hair long enough to interfere with eating and cause discomfort. The resident expressed that the mustache hairs were bothersome and wished for them to be trimmed. Facility policy required residents to be free of facial hair unless otherwise documented in the care plan, and staff interviews confirmed that grooming, including shaving, was to be performed during AM and PM care or as needed. However, the resident's grooming needs were not met as required by policy. Another resident reported not receiving scheduled showers for at least two weeks, despite being dependent on staff for bathing and being scheduled for showers three times weekly. The resident stated that staff told him he could not be showered due to the lack of a shower bed, although observations confirmed that both a shower bed and a shower chair were available for use. Staff interviews revealed confusion regarding the resident's shower schedule and an inability to confirm when the last shower was provided. The resident continued to request showers, indicating that his hygiene needs were not being met according to facility policy and his care plan.
Facility Fails to Maintain Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, functional, and sanitary environment for its residents, as evidenced by multiple observations during the survey. Resident #7's room was found with dried, glossy, tan-colored spots on the oxygen concentrator, infusion pole, and over-the-bed table. Additionally, the Day Room on Unit 4 was cluttered with trash, including food and other debris, while a resident was present in the room. Resident #8's room was observed to have a floor littered with various items, including candy wrappers, crayon wrap paper, and food remnants. The room also had a dusty and dirty air conditioner, a stained bed frame, and a privacy curtain with brown spots. Notably, there were roaches observed crawling on the floor and wall near the resident's bed. The Assistant Administrator confirmed the need for cleaning and acknowledged the presence of pests. Further observations revealed that Resident #2's room had numerous dried, glossy spots on the air conditioner, and Resident #4's room was littered with trash and had stained walls and furniture. Interviews with the Housekeeping Director and Maintenance Director highlighted issues with staffing and maintenance logs, contributing to the unsanitary conditions. The facility's Administrator acknowledged the conditions and mentioned hiring new housekeeping staff to address the issues.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely and routine incontinence care for a resident who required assistance with toilet use and hygiene. The resident, who had severe cognitive impairment and was always incontinent of bowel and bladder, was not checked or provided care for incontinence needs for a period of three and a half hours. This lapse occurred between 12:30 PM and 4:00 PM, during which time the resident was observed with wet incontinence briefs and clothing that smelled of urine. The facility's policy required that incontinent residents be checked at least every two hours, as needed, and upon request, but this was not adhered to in the case of the resident. Interviews with staff revealed that the Certified Nurses' Aide (CNA) assigned to the resident's care left after lunch without making rounds or checking on incontinent residents. The subsequent CNA, who took over at 1:30 PM, did not check the resident until 4:00 PM. The Licensed Practical Nurse (LPN) and the Director of Nurses (DON) confirmed that the resident was not monitored for incontinence during this period, and acknowledged that the delay in care was too long. The facility's failure to ensure timely incontinence care was further compounded by staffing issues, as repeated episodes of staff not working scheduled hours were noted to potentially affect resident care.
Failure to Adhere to Enteral Feeding Orders
Penalty
Summary
The facility failed to provide care and services to a resident with a feeding tube according to the resident's needs and consistent with the practitioner's orders. The deficiency was identified for a resident who relied on enteral feeding for nutrition. The facility's policy on enteral nutrition, dated 2017, outlined that tube feeding should be individualized, allowing for potential downtime for personal care or rehab therapy sessions. However, observations revealed that the resident's enteral feeding pump was turned off for over four hours, contrary to the physician's order to hold the feeding for only 30 minutes prior to meals. The Licensed Practical Nurse (LPN) expressed confusion regarding the physician's orders for the resident's enteral feeding, stating that the feeding was supposed to be turned off for an hour before the delivery of the resident's supper tray. The Director of Nursing (DON) confirmed that the feeding should not have been held for more than 30 minutes, as prolonged interruption could affect the resident's nutritional and hydration needs. The resident, admitted with diagnoses including Aphasia, Gastrostomy status, Diabetes, and Metabolic Encephalopathy, was observed with the enteral feeding pump off and the feeding bottle unchanged for several hours, indicating a failure to adhere to the prescribed feeding schedule.
Staffing Shortages Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff to meet the needs of residents on eight out of sixteen staffing days reviewed in December 2024. Observations and interviews revealed that staff shortages led to inadequate care, such as delayed incontinence monitoring and care for residents. An anonymous complaint highlighted a lack of housekeeping staff and inadequate direct care staff, which was corroborated by staff interviews and record reviews. Certified Nursing Assistant (CNA) #1 reported being unable to provide timely care due to an increased workload after another CNA left mid-shift. Interviews with staff indicated that late arrivals and call-ins were common, affecting the facility's ability to maintain adequate staffing levels. The Staff Development Director admitted to not using the Facility Assessment Tool for scheduling, relying solely on census numbers, which contributed to the staffing issues. The Director of Nurses (DON) confirmed that call-ins were problematic and that staff sometimes left residents in bed or skipped showers due to low staffing levels. Additionally, CNAs were occasionally reassigned to work in the laundry due to a lack of housekeeping staff, further impacting resident care. Resident #1, who was admitted with diagnoses of Heart Failure, Chronic Obstructive Pulmonary Disease, and Diabetes, reported waiting up to an hour for assistance on multiple occasions. The facility's staffing grid showed that the number of CNAs and licensed nurses often fell short of the required numbers based on the Facility Assessment Tool. The Administrator acknowledged the issues and confirmed that the Staff Development Director was expected to use the Facility Assessment Tool for staffing decisions, but this was not being done effectively.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by the conditions observed in the rooms of two residents, a shower room, and a hallway. Resident #3's room was found to be dirty, with trash and stains on the floor, dusty windows, and a black substance on the windowsills. The resident expressed dissatisfaction with the housekeeping services, and the Housekeeping Supervisor confirmed that the room should have been cleaned daily. Additionally, a family member of Resident #3 reported consistent issues with cleanliness during their weekly visits. Resident #4's room and the surrounding hallway were noted to have a strong urine odor. The resident, who had a history of urinary incontinence, was waiting for assistance from a CNA to change her bedding. Both the CNA and an RN confirmed the presence of the odor, and the Administrator suggested that the mattress might need cleaning or replacement. This indicates a failure to promptly address the resident's incontinence needs and maintain a clean environment. The shower room on the back hall was observed to have brown stains on the floor, which were easily wiped away, indicating a lack of regular cleaning. The assigned housekeeper admitted to not cleaning the floor on the days in question due to her workload. Additionally, the hallway outside a resident's room had decorative items covered in thick dust and dirty hand sanitizer dispensers, which the Housekeeping Supervisor acknowledged needed cleaning. The Administrator confirmed that housekeeping services were expected daily, but staffing challenges were impacting the facility's ability to maintain cleanliness.
Failure to Ensure Proper Food Storage and Labeling
Penalty
Summary
The facility failed to ensure foods were stored safely in the walk-in refrigerator and freezer. During an initial tour of the kitchen, it was observed that clear containers with unknown substances were neither labeled nor dated with use-by dates. Additionally, containers and boxes of food were stored on the floor in the walk-in freezer. The facility's policies on labeling and dating foods, as well as food storage, were not followed, which require all foods to be properly labeled and stored at least six inches above the floor to prevent contamination. Interviews with the Registered Dieticians (RD #1 and RD #2) and the Administrator revealed that the Dietary Manager, who was responsible for labeling and dating potentially hazardous foods (PHFs) and ensuring proper food storage, had been out sick and decided not to return. The Administrator confirmed that the facility had recently undergone a Mississippi State Department of Health (MSDH) food establishment inspection and received a C rating. The dietary staff was expected to follow the food storage and labeling policies in place, but these expectations were not met, leading to the observed deficiencies.
Failure to Notify Physician of Repeated Medication Refusals
Penalty
Summary
The facility failed to ensure the attending physician was notified of repeated medication refusals for a resident. The resident, who had diagnoses including Metabolic Encephalopathy, Unspecified Dementia, and Atrial Fibrillation, refused medications eight out of 29 days in February 2024 and only took medications for three out of 13 days in March 2024. Despite the facility's policy requiring notification of the physician and responsible party after repeated medication refusals, this was not consistently done. The Director of Nursing confirmed that the nurse should document refusals and notify the physician and responsible party, but this procedure was not followed in this case. Interviews with the Pharmacy Consultant, the resident's Physician, and the Nurse Practitioner revealed that they were not aware of the extent of the resident's medication refusals. The Pharmacy Consultant stated he does not always review the eMAR, and the Physician and Nurse Practitioner were not informed of the numerous missed doses. The resident's Physician emphasized the importance of the missed medications, particularly Eliquis, which is critical for preventing further complications. The Nurse Practitioner noted that the facility's use of agency staffing might contribute to the inconsistency in medication administration. The resident's Resident Representative (RR) also confirmed that she was not notified of the medication refusals. The facility's documentation showed only three notes indicating that the Nurse Practitioner was notified and only one note stating that the Resident Representative was informed. The Director of Nursing and the Administrator admitted they were unaware of the extent of the medication refusals and confirmed there was no system in place to address the issue. The resident's Quarterly Minimum Data Set (MDS) indicated severe cognitive impairment, further highlighting the need for diligent medication management and communication with the responsible parties.
Failure to Provide Clean Linen for Residents
Penalty
Summary
The facility failed to maintain a clean, homelike environment by not ensuring clean linen was available for two residents. Resident #120 was observed lying in bed with a strong odor in the room, indicating a need for incontinent care. Despite turning on the call light, the resident did not receive the necessary care for 30 minutes, and the CNA revealed that there were no clean sheets available. The resident had to sit up in a chair because of the lack of clean sheets, a situation that reportedly occurred several times a week. Resident #120 had severe cognitive impairment and multiple diagnoses, including seizures and diabetes mellitus. Resident #194 was found lying in bed without a fitted sheet on the mattress and stated that the facility often ran out of sheets. The resident, who was cognitively intact and required moderate assistance for mobility, confirmed that this issue was recurrent. Interviews with the DON, laundry supervisor, and other staff revealed that the facility had linen available, but staff were either unaware of its location or used the lack of linen as an excuse not to change beds. The facility had previously conducted an in-service training on linen locations, but many of the trained staff no longer worked at the facility.
Medication Error Rate Exceeds 5%
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, as evidenced by not administering medications per physician's orders for four out of 33 medications, resulting in a 12.12% medication error rate. Specifically, a Licensed Practical Nurse (LPN) administered Aspirin, Sertraline, Multivitamin with minerals, and Amlodipine to a resident via a PEG tube, despite the physician's orders indicating these medications were to be given by mouth. The LPN confirmed the error after reading the medication orders post-administration. The Director of Nursing (DON) reviewed the medication orders and confirmed that the medications were indeed ordered to be given by mouth. The DON stated that any variation from the physician's orders would be considered a medication error. The resident's physician orders, dated from November 2023, specified the oral administration of the medications, which was not followed, leading to the identified deficiency.
Unpalatable and Unappealing Food
Penalty
Summary
The facility failed to serve food in a manner that was appealing and palatable for two residents. Resident #5, who has Type 2 Diabetes Mellitus and Iron Deficiency Anemia, stated that the food tasted like slop and only consumed cold cereal and milk. This resident was cognitively intact with a BIMS score of 15. Similarly, Resident #362, who has diagnoses including Encounter for other Orthopedic Aftercare and Essential Hypertension, complained that the food tasted bad and was not appealing. This resident also had a BIMS score of 15, indicating cognitive intactness. On a subsequent day, a lunch tray was tested with the Dietician, revealing that the vegetables were bland and lacked taste. The Dietician acknowledged that the carrots could be sweeter and noted that some residents complain about the food being too salty or spicy. Resident #362 ate only 50% of the lunch meal and had previously complained to a CNA about the food, preferring fresh fruits and vegetables, which she kept in her personal refrigerator. These observations and interviews indicate that the facility did not meet the requirement to ensure food and drink were palatable, attractive, and at a safe and appetizing temperature.
Failure to Provide Scheduled Smoking Breaks
Penalty
Summary
The facility failed to ensure that residents who smoked were allowed to exercise their right to smoke during the designated smoking times. Resident #6 reported not receiving scheduled smoking breaks and observed staff engaging in horseplay instead of assisting residents. Resident #6, who has a diagnosis of Nicotine Dependence and is cognitively intact with a BIMS score of 15, expressed frustration and felt disrespected by the staff's inaction. Similarly, Resident #27 reported inconsistent smoking breaks, with delays of up to an hour or missed breaks entirely. Resident #27, also diagnosed with Nicotine Dependence and cognitively intact with a BIMS score of 13, observed staff idling at the nurse's desk during scheduled smoking times, further contributing to feelings of frustration and disrespect. Interviews with staff, including a CNA and the Director of Nursing, confirmed that residents were often ready for their smoke breaks, but staff were not available to assist them. The Director of Nursing acknowledged the issue and indicated that Unit Managers were responsible for assigning CNAs to take residents out for their smoke breaks. The Administrator, who had only been at the facility for three weeks, stated that he was still acclimating to the facility but expected staff to honor residents' preferences. The failure to provide scheduled smoking breaks negatively impacted the residents' feelings and their right to self-determination.
Failure to Resolve Grievance Related to ADL Care and Showering
Penalty
Summary
The facility failed to resolve a grievance related to Activities of Daily Living (ADL) care and showering for a resident with severe cognitive impairment. The resident, who has diagnoses including cerebrovascular disease, type 2 diabetes mellitus, unspecified convulsions, and essential hypertension, reported not receiving scheduled showers on multiple occasions. Despite being scheduled for showers three times a week, the resident only received bed baths during the observed period, leading to discomfort and complaints about dirty and itchy hair. Interviews with various staff members, including CNAs, social services, and nursing supervisors, revealed inconsistencies in the care provided to the resident. The resident's daughter had previously filed a grievance regarding the lack of proper ADL care, which led to an interdisciplinary team meeting and staff in-service. However, the grievance remained unresolved as the resident continued to miss scheduled showers, and staff were unaware of the ongoing issue. The facility's grievance policy requires prompt resolution of grievances, but the staff failed to follow through effectively. Social services and nursing leadership were not adequately monitoring the situation, and there was a lack of communication and documentation regarding the resident's care needs. The facility's reliance on agency staff further contributed to the inconsistency in care, as new staff were unfamiliar with the resident's specific requirements.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to ensure timely incontinent care for a resident, leading to the resident being left soiled for extended periods. Resident #167, who is dependent on staff for activities of daily living and is incontinent of bowel and bladder, reported having to wait long periods to be changed, especially during the night shift. Observations confirmed that the resident was found heavily soiled with urine and bowel movement, with a pillowcase placed between her legs to absorb the urine. The resident and her daughter had previously complained to staff about the issue, but the problem persisted. Interviews with staff, including CNAs, LPNs, and the DON, revealed inconsistencies in care practices and a lack of timely response to the resident's needs. The DON confirmed that residents should be checked and changed every two hours or more frequently as needed, but this standard was not met. The facility's policy on incontinent care was not followed, leading to the resident's prolonged discomfort and potential health risks. The facility's interdisciplinary team was aware of the complaints but failed to address them effectively.
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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