Choctaw Residential Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Choctaw, Mississippi.
- Location
- 135 Residential Center Rd, Choctaw, Mississippi 39350
- CMS Provider Number
- 255339
- Inspections on file
- 18
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Choctaw Residential Center during CMS and state inspections, most recent first.
The facility failed to protect residents from abuse when two residents with cognitive and behavioral issues inappropriately touched other residents in common areas without effective supervision. In one case, a cognitively impaired resident touched another resident’s leg and later was reported to have touched a female resident’s leg and between her thighs. In another case, a cognitively intact resident with prior documented inappropriate touching was confirmed by video to have touched a resident’s breast in a hallway. Affected residents reported the incidents to staff, but documentation was incomplete, follow-up with the victims was limited, and communication about the incidents and protective measures was insufficient, resulting in a failure to uphold residents’ rights to be free from abuse and to feel safe.
A facility failed to provide necessary behavioral health services and effective supervision to prevent inappropriate sexual contact between residents. In one case, a cognitively impaired resident with borderline intellectual functioning inappropriately touched another resident’s leg in a lobby area, and the affected resident later reported minimal follow-up and no documented assessment of the incident in her health status note. In another case, a resident with vascular dementia reported that another cognitively intact resident touched her breast in a hallway, despite prior documentation of that resident touching another resident inappropriately. In both incidents, residents were in common areas without effective supervision, and the facility did not proactively implement sufficient behavioral interventions or consistent behavioral health follow-up for the affected residents.
Several cognitively intact residents reported missing personal items, insufficient activities—especially on weekends—and excessive noise near the nurse's station, with complaints raised multiple times to staff and during council meetings. Despite these ongoing concerns, no formal grievances were filed, and the Administrator and key staff were unaware of the issues, resulting in unresolved resident complaints.
A resident with left hemiplegia and bilateral hand contractures was not provided with the care interventions outlined in their care plan, including the use of hand rolls, regular oral hygiene, and nail care. Observations and interviews confirmed that staff did not consistently follow the care plan, resulting in the resident being found with long, discolored nails, poor oral hygiene, and without prescribed contracture management devices.
Licensed nursing staff failed to follow professional standards for medication administration, resulting in two residents receiving discontinued, incorrectly scheduled, or incorrect forms of medication. In both cases, LPNs did not verify the six rights of medication administration, leading to errors such as giving a discontinued diabetes medication, administering an inhaler at the wrong time, documenting a medication that was not given, and providing the wrong form of aspirin to residents with complex medical conditions.
Three residents with intact cognition and significant medical histories reported that the facility did not provide structured group activities on weekends, offering only independent options like puzzles and coloring sheets. Staff confirmed the absence of weekend activity staff and lack of scheduled group activities, despite residents' documented preferences for such engagement.
A resident with severe hand and finger contractures, a history of cerebral infarction, and hemiplegia was repeatedly observed without the required bilateral hand rolls in place, despite care plans and therapy recommendations mandating their use every shift. Staff and therapy interviews confirmed the devices were not consistently applied, and facility policy required either application or documentation of reasons for omission.
Surveyors identified that the facility's medication error rate exceeded 5% after observing two LPNs who failed to verify the six rights of medication administration. Errors included administering a discontinued medication, giving a medication at the wrong time, documenting a medication as given when it was not, and providing the incorrect form of aspirin to two residents with complex medical conditions.
A medication cart was found unlocked and unattended in a hallway, contrary to facility policy requiring medication carts to be locked or under direct observation during medication passes. An LPN admitted to leaving the cart unlocked after being called away, and the administrator confirmed that this practice is not permitted as it could allow residents access to medications.
Surveyors found that the facility did not maintain a safe, clean, and homelike environment for several residents, including rooms with damaged walls and splintered plywood, persistent foul urine odors in a hallway and resident room despite repeated cleaning efforts, and a privacy curtain that was dirty and stained for an extended period. Staff and administrators confirmed these issues and acknowledged that they had not been resolved, impacting the comfort and safety of residents.
A resident who was totally dependent on staff for ADLs did not receive necessary oral and nail care, as evidenced by long, unclean fingernails and unbrushed teeth with visible buildup. Staff interviews confirmed the resident required total assistance and that aides were responsible for daily hygiene, but the care was not provided as observed.
Failure to Prevent and Adequately Address Resident-to-Resident Sexual Contact
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse by not preventing resident-to-resident inappropriate sexual contact and not providing effective supervision in common areas. Facility policy on Resident Rights, revised 3/24, states that each resident has the right to be free from mental and physical abuse and to have a safe, secure, and homelike environment, and that the facility is responsible for implementing interventions to prevent resident-to-resident altercations and to ensure supervision sufficient to protect residents from harm. Despite this policy, two separate incidents of non-consensual touching occurred between residents in common areas where supervision was ineffective. In the first set of incidents, one resident with borderline intellectual functioning and a BIMS score of 7, indicating severe cognitive impairment, inappropriately touched another resident with a cognitive communication deficit. On one occasion in the front lobby, the cognitively impaired resident approached the other resident and touched her leg without consent. The affected resident reported that she told him to stop and he left her alone, and she informed staff shortly after the incident. She stated that a nurse spoke with her once about what happened, but there was no further follow-up discussion or additional inquiries from other staff, and she did not receive updates on the outcome of the investigation. A later nurse’s note documented that a female resident reported this same resident inappropriately touched her twice on her leg and between her thighs, again requiring staff intervention to separate the residents. The affected resident later expressed concern that the alleged perpetrator’s name remained on the room across from hers and reported that she planned to avoid him and common areas if he returned. In the second incident, another resident with a cognitive communication deficit and a BIMS score of 13, indicating cognitive intactness, was observed and reported to have engaged in inappropriate touching of other residents. A health status note documented that this resident had previously been noted touching another resident inappropriately at the nurses’ desk and did not respond to redirection. Subsequently, a resident with vascular dementia and a BIMS score of 8, indicating moderate cognitive impairment, reported that this same resident touched her breasts without consent in the hallway in front of the nurse’s station. She immediately notified a CNA and clearly described that the resident had touched her breasts. The facility’s investigation, including review of camera footage, confirmed that the resident touched her breast while passing her in the hallway. Record review and interviews revealed that in both sets of incidents, the residents were in common areas without effective supervision at the time of the events, and although staff responded after the incidents occurred, the facility did not implement sufficient interventions to prevent the inappropriate resident-to-resident contact prior to the incidents. Interviews with the LNHA and the social worker further described gaps in the facility’s response related to the affected residents’ ongoing needs after the incidents. The LNHA acknowledged that while the facility determined that inappropriate contact had occurred and that staff responded once the incidents were reported, there were areas where the response could have been improved for the affected residents. She stated that the facility should have implemented more consistent and ongoing follow-up with the affected residents, including routine check-ins to assess fear, anxiety, or other psychosocial effects, and stronger communication with them regarding the protective measures in place. The social worker similarly acknowledged that the affected residents should have received more focused follow-up and supportive services after the allegations were made, including assessment of their immediate emotional and psychological needs, private discussions, validation of their concerns, and ensuring they felt heard. These statements, combined with the lack of documentation of the inappropriate touching in at least one resident’s health status note, demonstrate that the facility did not fully carry out its responsibility under its own Resident Rights policy to ensure residents were protected from abuse and that their concerns were adequately addressed. Record review confirmed that in both incidents, the residents were in common areas without effective supervision at the time of the events. Although staff separated residents and assessed for injuries after the incidents were reported, the facility failed to implement sufficient preventive interventions and supervision to stop the inappropriate resident-to-resident contact from occurring in the first place. The combination of ineffective supervision in common areas, repeated inappropriate touching by certain residents, incomplete documentation of the incidents in the affected residents’ records, and limited follow-up and communication with the affected residents led to the deficiency in protecting residents from abuse and ensuring their right to a safe and secure environment as required by facility policy.
Failure to Provide Necessary Behavioral Health Services and Supervision for Inappropriate Sexual Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents received necessary behavioral health care and services, specifically by not proactively assessing and implementing effective behavioral interventions to address inappropriate sexual behaviors between residents. Facility policy on Resident Rights states that each resident has the right to be free from mental and physical abuse and to have a safe, secure, and homelike environment, and that the facility is responsible for implementing interventions to prevent resident-to-resident altercations and to ensure supervision sufficient to protect residents from harm. The facility’s Behavioral Health Services policy further requires that all residents receive necessary behavioral health services to help them reach and maintain their highest level of mental and psychosocial functioning. One incident involved a resident with borderline intellectual functioning and severe cognitive impairment, who approached another resident with a cognitive communication deficit while both were seated in the front lobby and touched her leg without consent. The cognitively impaired resident had a BIMS score of 07, indicating severe cognitive impairment. The resident who was touched reported the incident to staff and stated she told him to quit and he left her alone. She later reported that she only spoke once with a nurse about what happened, that there was no further follow-up discussion or additional inquiries from other staff, and that she did not receive any updates regarding the outcome of the investigation. Her health status note for the date of the incident contained no documentation of the inappropriate touching. She also reported seeing the other resident’s name still listed on the room across from hers and stated she planned to avoid him and common areas if he returned. Record review showed that another female resident later reported that the same cognitively impaired resident inappropriately touched her twice on her leg and between her thighs. A separate incident involved a resident with vascular dementia and moderate cognitive impairment, who reported that another resident with a cognitive communication deficit and a BIMS score indicating intact cognition touched her breast without consent in the hallway in front of the nurse’s station. The resident who was touched immediately notified a CNA and clearly described that the other resident had touched her breast. Facility records showed that this same resident with intact cognition had previously been noted at the nurses’ desk touching another resident inappropriately and, when redirected, simply looked at the nurse and continued rolling in his wheelchair. In both incidents, record review revealed that the residents were in common areas without effective supervision at the time of the events. Although staff responded after the incidents occurred, the facility did not implement sufficient proactive interventions or supervision to prevent inappropriate resident-to-resident contact before these incidents took place, and affected residents did not receive consistent, documented behavioral health follow-up and support as required by facility policy.
Failure to Timely Resolve Resident Grievances Related to Missing Property, Activities, and Noise
Penalty
Summary
The facility failed to resolve resident grievances in a timely manner for four residents who participated in the resident council, specifically regarding missing clothing, insufficient activities, and excessive noise. One resident, who served as the Resident Council President and was cognitively intact, reported missing several clothing items to staff on multiple occasions. Despite the Ombudsman notifying the Case Manager about the missing items, no grievance form was completed, and the status of the missing clothing remained unresolved. The Social Services staff, responsible for completing grievances, confirmed that a grievance was not filed for this issue, and the Administrator was unaware of the situation until the day of the survey. During a resident council meeting, several residents expressed dissatisfaction with the lack of activities, particularly on weekends, and the noisy environment near the nurse's station at night. Residents reported that their concerns about limited activities and excessive noise, especially on weekends, had been raised multiple times with staff and during council meetings. One resident described being unable to sleep due to the noise, while another stated that staff were loud, played music, and gathered around the desk at night. These concerns were documented in previous council meeting minutes, but the Administrator was not aware of them, and no grievances were filed for these issues. Interviews with facility staff, including the Activity Director and Assistant Director of Nursing, revealed a lack of communication and follow-through regarding the residents' complaints. The Activity Director acknowledged the difficulty in planning activities for a diverse age group and confirmed that concerns discussed in resident council should be written up as grievances, but this was not consistently done. The Assistant Director of Nursing did not recall being informed about the noise complaints. All residents involved were cognitively intact and had voiced their concerns clearly, but the facility failed to document and address these grievances according to policy.
Failure to Implement Comprehensive Care Plan for Dependent Resident
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident who required total assistance with activities of daily living due to a history of cerebrovascular accident resulting in left hemiplegia and bilateral hand contractures. Despite the care plan specifying the use of bilateral hand rolls to prevent skin breakdown and further contracture, as well as regular oral and nail care, observations revealed that the resident was repeatedly found without hand rolls in place, had long, discolored nails (one of which was broken and hanging), and had a thick white substance on his teeth and gums. The resident reported that staff sometimes placed a hand towel in his hands instead of the prescribed hand rolls, and that oral care was not consistently provided despite his requests. Staff interviews confirmed that the care plan was not being followed, and the MDS nurse acknowledged that the purpose of the care plan was to guide staff in providing appropriate care. The resident was cognitively intact, as indicated by a BIMS score of 15, and was able to communicate his needs. The facility's own policy required the development and implementation of a comprehensive, person-centered care plan with measurable objectives and timeframes, but this was not adhered to for this resident.
Failure to Follow Professional Standards for Medication Administration
Penalty
Summary
Licensed nursing staff failed to follow professional standards of practice for medication administration, as evidenced by direct observation, record review, and staff interviews. In one instance, an LPN administered Glipizide 10 mg to a resident despite the medication having been discontinued two days prior. The same LPN also administered Albuterol Sulfate HFA inhaler at an incorrect time, as it had already been given earlier that morning, and documented the administration of Mometasone Furoate inhaler without actually giving it. The LPN did not verify the six rights of medication administration during these events. The resident involved had diagnoses including Type 2 Diabetes Mellitus and Chronic Systolic Congestive Heart Failure. In another instance, a different LPN administered Aspirin EC 81 mg to a resident without verifying the six rights of medication administration, resulting in the administration of the incorrect form of aspirin. The LPN later confirmed the error after reviewing the medication record. The resident involved had a diagnosis of End-Stage Renal Disease. In both cases, the LPNs acknowledged during interviews that they did not thoroughly check the six rights of medication administration, which contributed to the errors.
Failure to Provide Resident-Preferred Activities on Weekends
Penalty
Summary
The facility failed to provide activities that met the interests and preferences of residents, specifically for three residents who expressed a desire for structured group activities on weekends. Interviews with these residents revealed that while some activities were available during the week, there were no organized group activities on weekends, and only independent activities such as puzzles and coloring sheets were offered. Residents reported dissatisfaction with the lack of weekend activities and expressed that participating in their favorite activities was very important to them, as documented in their assessments. Staff interviews confirmed the absence of a dedicated activity staff member on weekends, with the Activity Director working only Monday through Friday. The charge nurse was responsible for assisting with independent activities on weekends, and church groups occasionally provided services, but no regular group activities were scheduled. The Administrator acknowledged the lack of structured weekend activities and stated efforts were being made to hire weekend activity staff. Activity calendars and attendance records corroborated that only independent activities were listed for weekends, and there was no documentation of resident participation in activities on those days. The residents involved had various medical diagnoses, including hemiplegia, hemiparesis following cerebral infarction, diabetes mellitus, chronic obstructive pulmonary disease, and dementia. All three residents were assessed as cognitively intact and indicated that engaging in their preferred activities was very important to them. Despite this, the facility did not provide activities tailored to their interests on weekends, resulting in unmet psychosocial needs as evidenced by resident and staff interviews, record reviews, and facility policy.
Failure to Consistently Apply Hand Rolls for Resident with Contractures
Penalty
Summary
A resident with a history of cerebral infarction and hemiplegia affecting the left nondominant side, who was cognitively intact, was observed multiple times without prescribed hand rolls in place for management of severe hand and finger contractures. The resident's care plan, as documented in the Treatment Administration Record and supported by occupational therapy recommendations, required bilateral hand rolls to be applied every shift to decrease the risk of skin breakdown and further contracture formation. Despite documentation indicating that the hand rolls were applied as ordered, direct observations on several occasions revealed that the resident did not have the hand rolls in place while in bed. Interviews with the resident, nursing staff, and the occupational therapist confirmed that the hand rolls were not consistently applied as required. The resident reported that staff sometimes placed a hand towel in his hands, but not consistently, and at the time of observation, no device was present. Nursing staff and the occupational therapist acknowledged the importance of the hand rolls and confirmed that failure to apply them could lead to worsening contractures and skin breakdown. The facility's policy stated that residents should not experience a reduction in range of motion unless clinically unavoidable, and the administrator confirmed that staff should either apply the hand rolls or document the reason for not doing so.
Medication Error Rate Exceeds 5% Due to Failure to Follow Six Rights
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a calculated error rate of 10.81% during the survey. This deficiency was identified through direct observation, record review, and staff interviews, revealing that licensed nursing staff did not consistently verify the six rights of medication administration. Specifically, one LPN administered a discontinued medication (Glipizide 10 mg) and gave an inhaler (Albuterol Sulfate HFA) at an incorrect time to a resident with Type 2 Diabetes Mellitus and Chronic Systolic Congestive Heart Failure. The same LPN also documented the administration of another inhaler (Mometasone Furoate) that was not actually given. The LPN admitted to not verifying the medication label against the medication administration record prior to administration. Another LPN was observed administering the incorrect form of aspirin (Aspirin EC 81 mg instead of the prescribed chewable tablet) to a resident with End-Stage Renal Disease. This LPN also failed to verify the six rights of medication administration by not checking the medication label against the medication record. Both LPNs acknowledged during interviews that their failure to follow proper medication administration procedures led to these errors.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
A medication cart located on C hall was observed to be unlocked and unattended during a survey, with no nurse in view. Facility policy requires that medications must be either under the direct observation of the person administering them or locked in the medication storage area or cart during a medication pass. An LPN confirmed that she had walked away from the cart and left it unlocked after being called away, acknowledging that this action allowed residents potential access to the medications. The facility administrator also confirmed that nurses are not permitted to leave medication carts unlocked and unattended, as this could allow residents to access the medications.
Failure to Maintain Safe, Clean, and Homelike Environment for Residents
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for multiple residents on one hallway, as evidenced by several direct observations and staff and resident interviews. In one instance, a resident's room had a large section of wall with missing paint and a piece of plywood with splintered, uneven edges behind the bed, which the resident expressed a desire to have repaired. The administrator confirmed that the condition of the wall and plywood could cause injury and did not meet the standard for a safe and homelike environment. Another resident's room and the adjacent hallway were noted to have an overpowering and persistent urine odor. Staff interviews revealed that the resident frequently urinated on the floor while attempting to use the toilet, and despite frequent mopping, floor replacement, and other interventions, the smell remained strong and unpleasant. Staff, including CNAs, an LPN, and the DON, acknowledged the ongoing nature of the odor problem and confirmed that it had led to complaints from other residents and family members. The administrator also confirmed awareness of the issue and that it had not been resolved, resulting in an environment that was not clean or comfortable for residents in that area. Additionally, another resident's privacy curtain was observed to be dirty and stained with large, discolored splotches. The resident stated that the curtain had not been cleaned for a long time, and both an LPN and the administrator confirmed the curtain was extremely dirty and needed cleaning. The facility's own policies required regular checking and cleaning of room curtains, but this was not followed, contributing to the failure to maintain a homelike environment.
Failure to Provide Required Oral and Nail Care for Dependent Resident
Penalty
Summary
A resident who was totally dependent on staff for personal hygiene, due to medical diagnoses including cerebral infarction and hemiplegia affecting the left nondominant side, did not receive necessary oral and nail care. Observations revealed the resident had fingernails approximately one inch long with a brown substance on each nail, and one nail was broken and hanging inside the palm. The resident's upper and lower teeth and lower gum line were covered in a thick white substance. The resident was observed in this condition on multiple occasions, and reported having previously asked staff to brush his teeth. Interviews with staff confirmed that the resident required total assistance for personal hygiene and that aides were responsible for daily oral care. A registered nurse acknowledged the potential for skin breakdown due to the resident's contracted fingers and confirmed the need for nail trimming. The administrator stated that staff were expected to perform and document these care tasks. Documentation confirmed the resident's total dependence on staff for ADLs, but the required care was not provided as observed.
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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