Comfort Care Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Laurel, Mississippi.
- Location
- 1100 West Drive, Laurel, Mississippi 39440
- CMS Provider Number
- 255352
- Inspections on file
- 6
- Latest survey
- November 18, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Comfort Care Nursing Center during CMS and state inspections, most recent first.
Surveyors identified multiple deficiencies in food storage and handling, including undated and unlabeled prepared foods, exposed and spoiled produce, and improper handling of ready-to-eat foods by staff using gloved hands. Dry goods were left uncovered, and items requiring refrigeration were improperly stored. Staff and administration acknowledged these lapses in food safety and sanitation protocols.
The facility did not promptly review or resolve repeated resident grievances about inadequate housekeeping, particularly on weekends when no dedicated staff were assigned. Multiple residents reported ongoing issues with unclean rooms and unemptied trash, and these concerns were documented over several months without effective response from management, despite their awareness of the problem.
Staff did not report allegations of verbal abuse by an LPN towards two residents, despite multiple accounts describing the nurse's behavior as loud and demeaning. Additionally, multiple reports of stolen resident funds were not reported to the State Agency, with the Administrator stating a lack of awareness of the reporting requirement. These actions were not in accordance with facility policy, which mandates immediate reporting of such incidents.
Two residents, both cognitively intact and with significant medical histories, reported being treated in a demeaning, intimidating, and disrespectful manner by an LPN, including raised voices, sarcastic remarks, and rough tones during medication administration. Staff interviews confirmed the LPN also used vulgar language and insults toward coworkers, contributing to an environment lacking in dignity and respect for both residents and staff.
Two cognitively intact residents reported that an LPN spoke to them in a loud, demeaning, and intimidating manner, with one resident feeling degraded and afraid after a medication-related interaction. Another resident described the LPN as using a rough tone and intimidating residents. Staff interviews confirmed the LPN's negative, vulgar, and insulting behavior towards both residents and staff, including the use of profane language. The facility's policy prohibits abuse, but these incidents demonstrate a failure to prevent verbal abuse.
Multiple residents reported theft of personal funds, with amounts ranging from $15 to over $100, from their rooms or belongings. Despite notifying the Resident Council President and various staff, including the Administrator, DON, and Social Service Director, residents did not receive updates or reimbursement. The Social Service Director confirmed forwarding statements to the Administrator but was unaware of any investigation outcomes. The Administrator acknowledged the reports but did not reimburse residents, citing uncertainty about the exact amounts. Residents affected had varying cognitive abilities and medical conditions, and the facility did not follow its policy to protect resident property.
A wound care cart containing medications such as Nystatin, Santyl, and Dakin's solution was left unlocked and unattended for fifteen minutes, with wound cleanser unsecured on top. An RN later returned to secure the cart. Both the RN and DON confirmed that the cart should have been locked at all times when not in use, in accordance with facility policy.
A third-party LCSW provided psychosocial therapy to multiple residents without informing facility staff, the physician, or resident representatives, as required by facility policy. The LCSW accepted self-referrals from cognitively intact residents and did not disclose service recipients, resulting in a lack of physician orders and no notification to responsible parties for the initiation of therapy.
The facility did not develop or implement care plans that included psychosocial therapy services provided by an LCSW for residents receiving such therapy. Staff confirmed that no documentation or care plan interventions reflected these services, as the LCSW, a third-party provider, refused to share resident information due to confidentiality. This resulted in a lack of coordination and individualized interventions for residents receiving therapy for depression or major depressive disorder.
The facility did not obtain physician orders for psychosocial therapy services provided by a third-party LCSW, resulting in therapy being delivered without appropriate physician oversight or documentation. Multiple residents received cognitive behavioral therapy for depression or related conditions, but there were no physician orders, referrals, or care plans in place, and the LCSW did not share session information with facility staff.
A Licensed Clinical Social Worker provided cognitive behavioral therapy to multiple residents without physician oversight, formal referral, or interdisciplinary coordination. The LCSW accepted self-referrals from cognitively intact residents and did not communicate with facility staff or medical personnel, resulting in a lack of psychosocial assessments, care planning, and monitoring for those receiving therapy.
A Licensed Clinical Social Worker provided individual psychosocial therapy to multiple residents but kept all therapy documentation separate from the facility's medical record system, resulting in incomplete and inaccessible records. Facility staff were unaware of which residents were receiving therapy or the details of the services, as the LCSW did not share any documentation, leaving the interdisciplinary team without access to pertinent clinical information.
The facility failed to submit accurate PBJ staffing data to CMS for December 2023, resulting in a report of no RN hours and less than 24 hours/day licensed nursing coverage for multiple days. The error was due to an interface issue, and staff were unaware of the inaccuracy.
Deficient Food Storage, Labeling, and Handling Practices Observed in Kitchen
Penalty
Summary
Surveyors observed multiple failures in food storage and handling practices during two kitchen inspections. In Refrigerator #1, several trays of prepared salads, bowls of pudding, fruit, and staff food were found without date labels, and some items were in direct contact with each other. Additional items, such as blueberry cobbler, fruit cocktail, and prefilled whipped topping, were also missing required labeling or were past their use-by dates. In Refrigerator #3, raw chicken tenders were left exposed with the lid off, cheese slices were left open and dried out, and produce such as strawberries and oranges were found to be spoiled or overly ripe. Dry storage bins for sugar, rice, and cornmeal were left uncovered, and an opened bag of grits was not securely closed. The Food Service Supervisor acknowledged these deficiencies and stated that it was his responsibility to ensure food safety. Further observations revealed unsanitary handling of ready-to-eat foods by kitchen staff. Staff members were seen using gloved hands to pick up and move bread and noodles directly on residents' plates, contrary to food safety protocols. An opened bottle of lemon juice requiring refrigeration was found improperly stored on a shelf. Interviews with staff confirmed awareness of proper food handling procedures, but lapses were attributed to forgetfulness. The Administrator acknowledged the issues with food storage, labeling, and unsanitary handling, emphasizing that all kitchen staff are responsible for maintaining food quality and sanitation.
Failure to Timely Address Resident Grievances Regarding Housekeeping
Penalty
Summary
The facility failed to review and resolve multiple resident grievances regarding housekeeping in a timely and effective manner, as evidenced by ongoing complaints documented in three consecutive months of Resident Council meeting minutes. Residents repeatedly expressed concerns about unclean floors, unemptied trash, and a lack of general housekeeping, particularly on weekends when no dedicated housekeeping staff were assigned. These grievances were raised during council meetings but did not receive a response or resolution from facility management. Specific residents reported that their rooms were left unclean throughout the weekend, with one resident managing persistent odors and unclean conditions due to accidents until staff returned on Monday. Interviews with the Housekeeping Manager and Administrator confirmed awareness of the complaints and acknowledged that staffing shortages, especially on weekends, contributed to the unresolved issues. Despite being aware of the ongoing concerns, the facility did not take prompt or effective action to address the grievances, resulting in persistent environmental issues for the residents.
Failure to Report Allegations of Verbal Abuse and Misappropriation of Resident Property
Penalty
Summary
The facility failed to ensure timely reporting of allegations of verbal abuse and misappropriation of resident property as required by federal regulations and its own policies. Specifically, staff did not report allegations of verbal abuse involving two residents, despite both the residents and a witness describing the LPN's behavior as loud, demeaning, and intimidating. The LPN admitted to speaking loudly, and a CNA corroborated the negative and vulgar conduct. The incident was not reported to the Director of Nursing, and the DON confirmed she was unaware of the situation, stating that staff are required to report such allegations and that the nurse would have been removed from resident care pending investigation if reported. Additionally, the facility failed to report multiple allegations of theft of resident funds involving five residents to the State Agency. The Administrator acknowledged that several residents had reported missing money but stated that reimbursement was not provided due to lack of verification of the amounts lost. The Administrator also admitted to not knowing that such incidents needed to be reported to the State Agency. The facility's policy requires immediate reporting of abuse and misappropriation allegations to appropriate authorities, but this protocol was not followed in these cases.
Failure to Ensure Residents' Right to Dignity and Respect by Nursing Staff
Penalty
Summary
Licensed nursing staff failed to treat residents with dignity and respect, as evidenced by multiple reports from both residents and staff. One resident reported that a night shift LPN raised her voice, spoke in a demeaning and intimidating tone, and argued with her about taking a newly prescribed medication that was causing stomach upset. The resident described feeling talked down to, afraid, degraded, and intimidated. The resident's roommate confirmed the LPN's loud and intimidating behavior, describing the interaction as uncalled for and rude. Another resident, who is a former CNA, also reported that the same nurse spoke to residents in a rough tone, used her authority to intimidate, and treated them like children, which she deemed inappropriate for the setting. Staff interviews further corroborated these concerns. A CNA reported that the LPN had spoken to her in a demeaning and vulgar manner, including the use of profanity and insults, leading the CNA to avoid working with the nurse. The facility scheduler confirmed that the CNA, who rarely complains, reported being verbally abused by the LPN during a night shift. Both the Administrator and the DON acknowledged that all residents have the right to be treated with dignity and respect. The residents involved were cognitively intact, as indicated by their BIMS scores, and had medical histories including hemiplegia, hemiparesis following cerebral infarction, and acute on chronic systolic congestive heart failure.
Failure to Protect Residents from Verbal Abuse by Staff
Penalty
Summary
The facility failed to protect residents from verbal abuse by staff, as evidenced by multiple interviews and record reviews involving two cognitively intact residents. One resident reported that a night shift LPN raised her voice, spoke in a demeaning and intimidating manner, and responded sarcastically when questioned about a new medication, making the resident feel degraded, afraid, and intimidated. The resident's roommate confirmed the LPN's loud and intimidating behavior, and another resident described the nurse as using a rough tone, talking down to residents, and using her authority to intimidate. Both residents expressed that the nurse's conduct was inappropriate and made them feel uncomfortable and fearful. Staff interviews corroborated the residents' accounts, with a CNA reporting that the same LPN was extremely negative, loud, vulgar, and insulting to both staff and residents during the shift in question. The CNA recalled the LPN using profane language towards staff and described her as intimidating. The facility scheduler confirmed that the CNA, who rarely complains, reported verbal abuse by the LPN, including cursing and name-calling. The Director of Nursing stated she had not been informed of the incident but noted a second, unrelated complaint about the same LPN's verbal abuse towards staff on the same night. The facility's policy prohibits abuse, neglect, and exploitation, but the events described indicate a failure to implement these protections.
Failure to Protect Residents from Misappropriation of Funds
Penalty
Summary
The facility failed to protect residents from misappropriation of their funds and did not implement corrective action or reimburse residents after multiple reports of missing money. Several residents reported to the Resident Council President and staff that their personal funds, ranging from $15 to over $100, were stolen from their rooms or personal belongings. Despite these reports, residents did not receive updates on the status of their complaints or any reimbursement for their losses. The facility's policy requires protection of resident property, but this was not followed in these cases. Interviews with residents revealed that they had reported the thefts to various staff members, including the Administrator, DON, Social Service Director, and security personnel. However, the residents consistently stated that no follow-up or resolution was provided. The Social Service Director confirmed that she collected statements and forwarded them to the Administrator, but was unaware of any investigation outcomes or reimbursements. The Administrator acknowledged the reports of stolen money but stated that, in his view, the facility was not obliged to reimburse residents unless the exact amounts could be confirmed. The affected residents had varying degrees of cognitive function, with some being cognitively intact and others having moderate impairment. Their medical histories included conditions such as heart disease, heart failure, anxiety disorder, anemia, and hemiplegia. The lack of action and communication from the facility left residents feeling unsafe, discouraged, and financially vulnerable, as their reports of missing funds were not addressed or resolved.
Unattended and Unlocked Wound Care Cart with Medications
Penalty
Summary
The facility failed to ensure that medications and biologicals were securely stored to prevent unauthorized access. On one of the survey days, a wound care cart located in the 200 Hall was observed to be unlocked and unattended for fifteen minutes, with wound cleanser left unsecured on top of the cart. The cart contained medications such as Nystatin, Santyl, Dakin's solution, and other wound care agents. The cart was only locked after a registered nurse returned, placed the unsecured cleanser inside, and secured the cart. Interviews with the registered nurse and the Director of Nursing confirmed that the cart should have been locked at all times when not in use, as per facility policy. The nurse explained that the keypad locking mechanism was malfunctioning, requiring manual locking, and admitted to forgetting to lock the cart after use. The Director of Nursing and the Administrator both acknowledged the expectation that all treatment carts remain locked and that no medications or supplies should be left unsecured.
Failure to Notify Physician and Resident Representative of Initiation of Psychosocial Therapy
Penalty
Summary
The facility failed to notify the physician and the resident representative (RR) when individual psychosocial therapy services were initiated for three sampled residents, with the potential to affect all 21 residents receiving such therapy. According to the facility's policy, notification of the resident, consultation with the physician, and notification of the RR are required when there are changes in treatment or services. However, a Licensed Certified Social Worker (LCSW) from a third-party provider delivered psychosocial therapy to residents without informing facility staff, the physician, or the RRs. The LCSW stated that all referrals were self-initiated by cognitively intact residents and did not share information about which residents were receiving services, citing confidentiality. Interviews with facility staff, including the Social Services staff member, Registered Nurse, Nurse Practitioner, and the physician, confirmed that they were unaware of which residents were receiving therapy from the LCSW. As a result, no physician orders were obtained, and no notifications were made to the RRs regarding the initiation of therapy. The Administrator acknowledged that the facility did not follow its own policy for physician and RR notification for residents receiving psychosocial services from the LCSW. Record reviews for the three sampled residents showed that each had a BIMS score indicating they were cognitively intact and had no documented behaviors or mood symptoms at the time of assessment. Documentation from the LCSW confirmed that these residents received Cognitive Behavioral Therapy for depression on multiple occasions, but there was no evidence in the medical records that the physician or RRs were notified about the initiation or continuation of these services.
Failure to Include LCSW Psychosocial Therapy in Resident Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed the psychosocial needs of residents receiving individual therapy from a Licensed Clinical Social Worker (LCSW). Specifically, the care plans for three sampled residents did not include the ongoing psychosocial therapy services provided by the LCSW, nor did they reflect coordination of care, consistent monitoring, or individualized interventions based on the residents' psychosocial needs. This omission was identified through record reviews, interviews with facility staff, and review of facility policy, which requires that all identified needs, including mental and psychosocial, be addressed in the care plan with measurable objectives and timeframes. Interviews with facility staff, including the Social Services Director, RN, LPN/MDS Coordinator, and ADON, confirmed that there were no behavioral care plan interventions or documentation related to the LCSW's services. The LCSW, who is a third-party provider and not employed by the facility, refused to share information about the residents she served, citing confidentiality. As a result, the facility was not informed of the therapy sessions, and no physician's orders or documentation were provided to support the inclusion of these services in the residents' care plans. The interdisciplinary team was not involved in developing or reviewing care plans related to these psychosocial therapy services. Record reviews for the three residents showed that each had received cognitive behavioral therapy from the LCSW for depression or major depressive disorder, with therapy provided on a regular basis. Despite this, their medical records and care plans did not reflect these services or any related interventions. The lack of documentation and care planning for these services affected not only the three sampled residents but also had the potential to impact all 21 residents who received psychosocial therapy from the LCSW.
Failure to Obtain Physician Orders for Third-Party Psychosocial Therapy Services
Penalty
Summary
The facility failed to ensure that psychosocial therapy services provided by a third-party Licensed Clinical Social Worker (LCSW) were delivered and documented according to professional standards. Specifically, the LCSW provided ongoing behavioral therapy to residents without obtaining physician's orders, and the facility did not have records of referrals, care plans, or notifications to resident representatives for these services. Interviews with facility staff, including the Social Services Director, RN, Assistant Director of Nursing, and the physician, confirmed that no physician's orders or referrals were in place for the residents receiving these services. The LCSW also did not share resident names or session documentation with the facility, citing confidentiality, and the facility's policy required physician's orders for all services provided to residents. Record reviews for three sampled residents revealed that each had received multiple sessions of cognitive behavioral therapy from the LCSW for conditions such as major depressive disorder and depression, despite having no documented behaviors or mood symptoms on their Minimum Data Set (MDS) assessments. The medical records for these residents did not contain any physician's orders reflecting the behavioral therapy they received. The deficiency was identified as having the potential to affect all 21 residents who received psychosocial therapy from the LCSW.
Failure to Coordinate and Oversee Behavioral Health Services Provided by External LCSW
Penalty
Summary
The facility failed to identify, assess, and coordinate behavioral health services for three residents who were receiving individual psychosocial therapy from a Licensed Clinical Social Worker (LCSW). The LCSW, employed by a local hospital's behavioral health program, provided ongoing cognitive behavioral therapy to residents within the facility without physician oversight, formal referral, or interdisciplinary coordination. The LCSW accepted self-referred residents, regardless of whether a clinical need had been identified, and did not communicate with facility staff, the nurse practitioner, or the physician regarding which residents were receiving services. Interviews with facility staff, including the Social Services Director, RN, ADON, Administrator, NP, and Physician, confirmed that there was no communication or coordination regarding the therapy services being provided. The facility was unable to conduct appropriate psychosocial assessments, implement monitoring interventions, or evaluate the effectiveness or necessity of the therapy. The LCSW stated that, due to confidentiality, she did not inform facility staff or medical personnel of the residents receiving therapy, and all referrals were self-initiated by cognitively intact residents. Record reviews showed that the LCSW provided therapy to 21 residents, including the three sampled residents, none of whom exhibited behaviors or mood symptoms according to their MDS assessments. There were no physician orders, care plans, or notifications to resident representatives regarding the therapy services. The lack of oversight and coordination resulted in the facility being unaware of the therapy being provided, with no monitoring or follow-up for changes in residents' psychosocial or behavioral health status.
Failure to Integrate Psychosocial Therapy Documentation into Medical Records
Penalty
Summary
The facility failed to maintain complete and readily accessible medical records for all residents receiving individual psychosocial therapy. Specifically, a Licensed Clinical Social Worker (LCSW) provided therapy to approximately 21 residents but kept all therapy documentation in a locked cabinet, separate from the facility's medical record system. The LCSW did not share progress notes or any documentation with the facility, citing confidentiality, which resulted in incomplete medical records for residents receiving these services. Facility staff, including the Social Services Director, RN, and Assistant Director of Nursing, confirmed that they did not have access to information about which residents were receiving therapy or the details of the services provided. Record reviews for three sampled residents revealed that while the LCSW documented therapy sessions and treatment plans, this information was not integrated into the facility's records. The sampled residents had various diagnoses, including fibromyalgia, sacral spina bifida, and hemiplegia, and were cognitively intact according to their MDS assessments. Despite receiving regular cognitive behavioral therapy for depression or major depressive disorder, there was no documentation of these services in the facility's medical record system, leaving the records incomplete and inaccessible to the interdisciplinary team.
Failure to Submit Accurate PBJ Staffing Data
Penalty
Summary
The facility failed to electronically submit accurate direct care staffing information based on payroll data to CMS for December 2023. A review of the Payroll Based Journal (PBJ) Staffing Data report revealed that the facility had triggered for four or more days within the quarter with no RN hours and four or more days within the quarter with less than 24 hours/day licensed nursing coverage from December 2, 2023, to December 31, 2023. The facility's policy on Nurse Staffing Information, revised in November 2023, did not address the accurate submission of PBJ data. The Business Office Coordinator, responsible for entering the PBJ data, stated she was unaware of the failure and did not receive any error messages or warnings after submission. The Director of Nursing (DON) also confirmed that she was not aware of any errors and stated that the facility always had adequate nursing staff and 24-hour RN coverage during the period in question. The Administrator confirmed that there was an interface error that resulted in the staffing data not being collected for the specified period. Despite the facility having adequate nursing staff and RN coverage, the data was not submitted accurately to CMS. The Administrator acknowledged that it was ultimately the facility's responsibility to ensure the accuracy of the submitted information, even though no feedback or alerts were received indicating an error. The deficiency was identified through staff interviews and record reviews, highlighting a lapse in the facility's data submission process.
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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