Chadwick Community Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Jackson, Mississippi.
- Location
- 1900 Chadwick Drive, Jackson, Mississippi 39204
- CMS Provider Number
- 255125
- Inspections on file
- 21
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Chadwick Community Care Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of wandering was discharged after going on therapeutic leave with family, but neither the resident nor their representative received a required bed-hold notice or clear communication about discharge status, appeal rights, or the process for returning. Facility staff confirmed that bed-hold notifications were not provided for therapeutic leave, and the resident's family experienced confusion regarding medication, discharge, and the removal of a wander guard.
A resident with significant neurological impairments and total dependence for ADLs did not receive perineal care according to the care plan, which required two-person assistance. Instead, a CNA provided care alone, contrary to the documented interventions. Facility leadership and nursing staff confirmed that the care plan was not followed during this incident.
A CNA failed to provide perineal care according to policy for a resident with neurological impairments, neglecting to clean all required areas and improperly handling a feeding pump, which only nurses are authorized to operate. Facility staff confirmed the care was not performed correctly and that the resident was unable to participate in a mental status interview.
A resident on Enhanced Barrier Precautions did not receive perineal care in accordance with infection control protocols. A CNA failed to wear a gown, perform hand hygiene, use a barrier for supplies, or change gloves as required, and did not properly clean the perineal area. Facility staff confirmed these actions did not meet established infection prevention standards.
A resident with severe cognitive impairment and a history of wandering exited the facility unsupervised through a kitchen door that lacked a wander guard alert system. Despite wearing a wander guard bracelet, the resident was able to leave undetected, as staff did not immediately notice the absence and the door was not properly secured. The resident was found approximately one mile away after crossing a busy highway, highlighting a failure in supervision and environmental safety controls.
The facility failed to provide adequate nursing staff, resulting in delayed responses to call lights and untimely incontinent care for residents. A resident experienced frequent delays, with observations noting a strong odor of urine and saturated briefs. Another resident reported long wait times for call light responses, with staff often failing to return. A third resident reported long wait times, particularly during the night shift, and a CNA confirmed staffing shortages. The DON and Administrator stated expectations for timely care, but observations indicated systemic staffing issues.
The facility failed to honor the rights of two residents who requested bedrails for assistance with mobility. Despite their requests, the facility removed all bedrails, citing state regulations and a restraint-free policy. The residents' needs and choices were not assessed, leading to a violation of their rights.
A resident receiving oxygen therapy at 2 L/min was found without a dated tubing and a humidifier, contrary to facility policy and physician orders. The resident, with a history of respiratory issues, had been hospitalized twice for shortness of breath. Staff interviews confirmed the oversight, highlighting the risk of infection and dryness due to non-compliance with weekly tubing changes and humidifier use.
A resident with moderate cognitive impairment and a history of stroke, diabetes, and heart disease experienced delays in receiving incontinent care. Despite activating the call light, staff either turned it off without providing care or delayed in responding. Observations showed the resident's brief was often saturated with urine, and the wheelchair was wet due to leakage. The facility had only one CNA for 12 residents, contributing to the delay, despite expectations for timely care set by the DON and Administrator.
Failure to Provide Bed-Hold Notice and Discharge Communication
Penalty
Summary
The facility failed to provide a required bed-hold notice to a resident and their representative when the resident went out on therapeutic leave, as required for Medicaid beneficiaries. The facility did not have a policy for issuing bed-hold notifications for therapeutic leave, and staff interviews confirmed that such notices were only given when a resident was admitted to a hospital for more than 24 hours, not for therapeutic leave with family. The Executive Director, Business Office Manager, and other staff acknowledged that bed-hold notifications were not provided in these circumstances, and the Executive Director later recognized this as an oversight. The resident involved had a history of schizophrenia and wandering, with a severely impaired cognitive status as indicated by a BIMS score of 03. The resident frequently went on therapeutic leave with family, as documented in progress notes and facility records. On the date in question, the resident left with family for therapeutic leave and did not return. The family and resident representative were not informed of a discharge at the time of departure, nor were they provided with information about bed-hold policies, appeal rights, or the resident's ability to return to the facility. Interviews with the resident's representative and family revealed confusion and lack of communication regarding the resident's discharge status, medication supply, and the process for returning to the facility. The representative reported not understanding the appeal process and not receiving timely or adequate notification about the resident's discharge or bed-hold rights. Additionally, the facility did not remove the resident's wander guard upon discharge, and there was no follow-up from the social worker regarding the resident's care after leaving the facility.
Failure to Follow Care Plan for Dependent Resident During Perineal Care
Penalty
Summary
The facility failed to implement the comprehensive care plan for a resident who was observed for activities of daily living (ADL) care, specifically during perineal care. The resident's care plan, initiated on 10/2/24, indicated that the resident was incontinent of bladder and bowel and required incontinent checks and care every two hours and as needed, with two-person assistance due to total dependence. However, during an observation on 9/16/25, a CNA provided perineal care to the resident without the required two-person assistance as specified in the care plan. Interviews with the CNA, Executive Director, and Director of Nursing confirmed that the care plan was not followed during the provision of care. The CNA acknowledged not using two-person assistance, and both the Executive Director and Director of Nursing stated that the expectation is for CNAs to follow the care plan and provide proper care. The resident involved had significant medical conditions, including hemiplegia, hemiparesis, dysphasia, and aphasia following cerebrovascular disease, and was unable to complete a mental status interview, indicating a high level of dependency and vulnerability.
Failure to Provide Proper Perineal Care and Unauthorized Handling of Feeding Pump
Penalty
Summary
A deficiency was identified when a Certified Nursing Assistant (CNA) failed to provide perineal care according to the facility's policy and accepted standards for a resident with significant neurological impairments, including hemiplegia, hemiparesis, dysphasia, and aphasia. During the observed care, the CNA used wipes to clean the resident's groin area but did not separate the labia or clean each side and the center thoroughly, nor did he clean the rectal area. The CNA also placed the resident's feeding pump on hold, an action that facility policy reserves for nurses only. The CNA acknowledged not following proper procedure and attributed the lapse to nervousness. Interviews with facility staff, including the RN Unit Manager, Executive Director, and Director of Nursing, confirmed that the CNA did not perform perineal care correctly and was not authorized to operate the feeding pump. The facility's policy requires thorough cleaning of the entire perineal area and mandates that only nurses handle feeding pumps. The resident involved was unable to participate in a mental status interview, as indicated by a BIMS score of 00, and had been admitted with multiple neurological diagnoses.
Failure to Follow Infection Control Protocols During Perineal Care
Penalty
Summary
The facility failed to provide perineal care in accordance with infection prevention and control protocols for one of two residents observed. During the observation, a CNA gathered supplies and entered the resident's room, which was under Enhanced Barrier Precautions (EBP), without donning a gown as required. The CNA placed supplies directly on the table without a barrier, did not perform hand hygiene before, during, or after care, and did not change gloves during the procedure. The CNA also failed to separate the labia to clean each side and the center individually, did not clean the rectal area, and placed soiled wipes and briefs on the bed instead of in a designated bag. After completing care, the CNA removed gloves and exited the room without washing or sanitizing hands. Interviews with facility staff, including the CNA, RN Unit Manager, Executive Director, DON, and Infection Preventionist, confirmed that the CNA did not follow established protocols for EBP, hand hygiene, and perineal care. Staff acknowledged that the CNA's actions constituted cross-contamination and did not meet the facility's expectations for infection control. The CNA admitted to not wearing a gown, not washing hands, and not following proper perineal care procedures, attributing the lapse to nervousness and oversight. The resident involved had a history of significant medical conditions, including hemiplegia, hemiparesis, dysphasia, and aphasia following cerebrovascular disease, and was unable to complete a mental status interview. Facility records and policy reviews indicated that staff were trained and expected to follow EBP and hand hygiene protocols, but these were not adhered to during the observed incident.
Failure to Prevent Elopement of High-Risk Resident Due to Inadequate Supervision and Environmental Controls
Penalty
Summary
The facility failed to provide adequate supervision to a resident identified as an elopement and wandering risk, resulting in the resident exiting the facility unsupervised. The resident, who had a diagnosis of Schizophrenia and severe cognitive impairment as indicated by a BIMS score of 4, was last seen in the dining room by staff. Despite being equipped with a wander guard bracelet, the resident was able to leave the facility through a kitchen door that was not equipped with a wander guard alert system, unlike other facility exits. The door had a keypad lock, but it was accessible from the dining area and not properly secured to prevent resident exit. Staff did not immediately notice the resident's absence. The resident's walker was left in the dining room, and staff initially assumed the resident had returned to his room. It was only after a phone call from the resident's family and subsequent checks that staff realized the resident was missing. A facility-wide elopement alert was then announced, and staff began searching the premises and surrounding area. The resident was located approximately one mile from the facility, having crossed a busy four-lane highway, and was returned after being unsupervised for about two hours. Interviews with staff and family confirmed that the resident had a history of exit-seeking behavior and had previously expressed a desire to go home. Staff had observed the resident attempting to open exit doors on multiple occasions. The facility's policy required staff to report any resident attempting to leave or suspected of being missing, but in this instance, the resident was able to leave undetected due to the lack of a wander guard system on the kitchen door and insufficient supervision in the dining area.
Removal Plan
- RN #2 performed a head-to-toe assessment with the resident's daughter, Executive Director, and DON present. There were no visible physical injuries.
- A 100% audit of all Wander/Elopement Risk residents were assessed for placement and proper functioning with no adverse findings.
- All the facility's entrance and exit door's alarm systems were checked. All the alarms were functioning properly.
- Resident #1 checked for wander guard placement and properly working. His wander guard was intact and working properly.
- Head-to-toe assessment of Resident #1 completed by the Unit B Manager and DON. There were no negative findings.
- Resident #1 was interviewed by the Unit B Manager. No negative statements were made by the resident.
- Upon Resident #1's return he was placed on 1:1 location monitoring x (times) 72 hours then tapered down to every 15 minutes then every 30 minutes then every hour. The Unit Manager, DON, and Social Services will determine when the resident may be removed from 1:1. The resident was placed on 24 hours charting for the nurses to document and notifying the MD/NP of any significant changes in the resident physical or mental status.
- A keypad lock was placed on the kitchen entrance door in the dining room by the Housekeeping Supervisor. The Housekeeping Supervisor replaced the old door handle on the kitchen door next to Unit-B with a keypad. The code will be given to dietary workers and key staff.
- The Maintenance Supervisor contacted Systronic Alarms Systems on installing a wander guard alarm on the kitchen door leading to the loading dock. A representative from the company will be at the facility.
- Resident #1 was moved closer to the nurses station. He moved from B 118P to B 108P. The Elopement Wander guard book reviewed. The Elopement Book was correct. A 100% check of the Wander/Elopement Risk were assessed for placement and proper functioning.
- The Dietary Workers on shift during the time of the incident received 1:1 Educational In-Services on Exit Doors in the kitchen and written corrective counseling by the Executive Director.
- Educational In-services for the facility's staff conducted by the Staff Development/Executive Director were initiated and included: a) Exit Doors in the kitchen b) Resident's Rights c) Abuse Prevention and Reporting d) Abuse and Neglect e) Residents expression to go home f) Missing Resident/Elopement.
- The Unit B Manager re-schedule Resident #1's eye appointment. Resident's appointment is scheduled as a follow-up consult visit to rule out retinal vein occlusion with macula edema to the left eye.
- Resident #1's care plan and pain assessment up-dated. Social Services Director preformed a Trauma Screen.
- The facility prepared a formal letter to mail to each resident's representative. The letter requests that during visits, if the resident expresses wish to leave the facility or return home, the family should inform nurse management, the Executive Director, or Social Services.
- We had a Family Meeting with Resident #1's daughter. The daughter did not express any concerns about her father's care or safety with the facility.
- Nursing will review 24 hour progress notes on the following week day and/or Monday following the weekend for any resident's voicing wanting to go home or exhibits exit seeking behavior to ensure proper intervention are in place.
- A QAPI was implemented with an emergency QA meeting reviewing Resident #1's incident.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by delayed responses to call lights and untimely incontinent care for three residents. Resident #48 experienced frequent delays in receiving care, with observations noting a strong odor of urine and saturated briefs. The resident reported that CNAs often turned off call lights without returning promptly, and the facility was observed to have only one CNA attending to 12 residents on the hall. The Director of Nurses and an LPN acknowledged the delay, attributing it to staffing shortages. Resident #87 also reported long wait times for call light responses, with staff often failing to return after initially acknowledging the call. This resident, who was cognitively intact, expressed frustration with the consistent delays across all shifts. Similarly, Resident #23 reported long wait times, particularly during the night shift, and a CNA confirmed that the facility was often short-staffed, with nurses not assisting CNAs. The Director of Nurses and the Administrator both stated expectations for timely care, but the observations and interviews indicated a systemic issue with staffing levels and response times.
Failure to Honor Resident Choice for Bedrails
Penalty
Summary
The facility failed to honor the rights of two residents, who expressed a desire to have bedrails for assistance with turning and bed mobility. Resident #54, who was cognitively intact, reported wanting bedrails to maintain some independence, but was informed by staff that state regulations prohibited their use. Similarly, Resident #78, who had moderate cognitive impairment and required assistance with mobility, expressed frustration over the removal of his bedrails, which he used for turning assistance. Both residents were told that the state regulations were the reason for the removal of bedrails, and their requests for bedrails were not assessed or honored. The facility's management confirmed that all bedrails were removed from residents' beds, citing state regulations and the facility's restraint-free policy as reasons. However, it was acknowledged that the removal of bedrails without assessing individual resident needs or choices was a violation of residents' rights. The facility did not have a specific bedrail policy in place, only a restraint policy, which contributed to the oversight in addressing the residents' requests and needs for bedrails.
Failure to Follow Oxygen Therapy Protocols
Penalty
Summary
The facility failed to ensure proper oxygen therapy for a resident, as evidenced by not following physician orders or facility policies. During an observation, it was noted that a resident was receiving oxygen at 2 liters per nasal cannula without a date on the tubing and without a humidifier attached. The resident had a history of shortness of breath and acute respiratory failure with hypoxia, and had been hospitalized twice due to shortness of breath. The facility's policy required oxygen tubing to be changed and dated weekly, and a humidifier to be used if needed to prevent dryness in the nasal area. Interviews with staff, including an LPN and the Director of Nurses, confirmed the oversight. The LPN acknowledged the absence of a date on the tubing and the lack of a humidifier, stating that these omissions could lead to infection issues. The Director of Nurses also confirmed that the resident should have had a humidifier attached to the oxygen delivery system to maintain moisture in the nasal area and that the tubing should be changed weekly to prevent bacterial growth. The physician's orders for the resident specified continuous oxygen at 2 L/min and weekly tubing changes, which were not adhered to.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide timely incontinent care for a resident, leading to a deficiency in care. The resident, who has a history of cerebral infarction, type 2 diabetes mellitus, and hypertensive heart disease, was observed to have a moderate cognitive impairment and required substantial assistance with toileting and personal hygiene. On multiple occasions, the resident's call light was activated, indicating a need for assistance, but staff either turned off the light without providing care or delayed in responding. The resident expressed frustration over the long wait times for care, which occurred across different shifts. Observations revealed that the resident's incontinent brief was often soiled and saturated with urine, and the resident's wheelchair was also wet due to leakage. Interviews with staff, including CNAs and the DON, confirmed that there was only one CNA available for 12 residents on the hall, which contributed to the delay in care. Despite the facility's policy and the expectations set by the DON and the Administrator for timely care, the resident continued to experience delays in receiving necessary assistance, resulting in a strong odor of urine in the resident's room and hallway.
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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