Great Oaks Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Byhalia, Mississippi.
- Location
- 111 Chase Street, Byhalia, Mississippi 38611
- CMS Provider Number
- 255311
- Inspections on file
- 23
- Latest survey
- November 6, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Great Oaks Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with significant cognitive impairment and multiple medical conditions returned from a hospital stay without previously ordered interventions, such as an abduction pillow and nutritional supplement, being reinstated. Facility staff did not contact the provider to clarify whether these interventions should be resumed, and there was no policy guiding the review or transcription of readmission orders, resulting in a lapse in continuity of care.
A resident with cognitive impairment and dependent mobility was found to have bilateral femoral neck fractures of unknown origin. The facility's investigation was inconclusive and lacked key documentation, yet the incident was not reported to the State Agency as required by policy, due to the belief that the injuries were pathological.
A resident who was cognitively impaired and dependent for transfers sustained bilateral femoral neck fractures and facial bruising, with the injuries not identified until a later hospital visit. The facility's investigation into the injuries was incomplete, lacking staff witness statements, comprehensive documentation, and timely communication with the responsible party, resulting in an inability to determine the cause of the injuries.
A verified therapy order for a resident with multiple medical conditions and cognitive impairment was not entered into the electronic medical record after being reviewed and signed by an NP. As a result, the ordered therapy services were not initiated, and the resident's clinical record was incomplete. The DON and administrator confirmed the lack of documentation and absence of a policy for transcribing orders into the system.
A resident with a history of falls and moderate cognitive impairment suffered a head laceration requiring ER treatment after staff removed bed rails without a safety assessment or alternative interventions. The resident rolled out of bed during care, and staff confirmed no individualized assessment or additional safety measures were implemented following the removal of the rails.
The facility experienced significant staffing shortages, particularly during night shifts, leading to delayed responses to resident needs. The DON and ADON often covered shifts themselves due to high staff turnover and frequent call-ins. Residents reported long wait times for assistance, with some waiting over an hour for call lights to be answered. The facility's staffing grid confirmed insufficient CNA coverage, despite a census of fifty residents, many requiring two-person assistance. The Administrator believed staffing was adequate, despite resident complaints.
A CNA in an LTC facility misappropriated a resident's funds by using her debit card without permission to order food for herself. The resident initially allowed the CNA to use her card due to a lack of access to a food app, but the CNA continued unauthorized use, leading to multiple charges. The resident's husband discovered a pending charge, prompting an investigation that revealed the CNA's actions. Despite training on abuse and misappropriation, the CNA violated policy, resulting in financial exploitation.
A resident's Hydrocortisone medication was discontinued by the FNP based on a pharmacist's recommendation without notifying the resident's representative (RR). The facility's policy required such notifications, but the ADON assumed the FNP would address it later. The medication was reinstated after the RR explained its importance.
Failure to Clarify and Resume Pre-Hospital Interventions After Readmission
Penalty
Summary
The facility failed to notify the provider to clarify missing orders for previously established interventions after a resident returned from the hospital. Prior to hospital transfer, the resident had orders for an abduction pillow and a nutritional supplement, but these were not mentioned in the hospital's After Visit Summary upon readmission. The facility did not contact the provider to determine if these interventions should be resumed, resulting in the interventions not being reinstated. Interviews with the ADON, DON, and the Administrator confirmed that no clarification was sought regarding the continuation of these interventions, and there was no policy in place for reviewing or transcribing readmission orders to address such situations. The resident involved was admitted with multiple diagnoses, including malignant neoplasm of the cervix, protein-calorie malnutrition, vitamin D deficiency, and bilateral femoral neck fractures. The resident was cognitively impaired, with a BIMS score of 1, and was dependent for transfers and non-ambulatory. The lapse in continuity of care occurred because the facility did not verify whether to continue previously established interventions following the resident's return from the hospital.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the State Agency as required by its Abuse Prohibition Policy. The policy mandates that the Abuse Coordinator report injuries of unknown source with serious bodily injury within two hours of the allegation. In this case, a resident with significant cognitive impairment and dependent for transfers was found to have bilateral displaced femoral neck fractures, which were identified during a hospital evaluation for seizure-like activity. The investigation into the cause of the fractures was inconclusive, with possible causes including a pathological process, seizure activity, or a rough transfer by EMS, as reported by the resident's responsible party. Despite the inability to determine the cause of the fractures, the facility did not report the incident to the State Agency, believing the injuries to be pathological. The investigation file lacked documentation such as staff witness statements, records of conversations with the responsible party prior to the injury, and supporting evidence for the conclusion that the fractures were pathological. The administrator later acknowledged that the cause could not be determined and that the incident met the definition of an injury of unknown origin that should have been reported.
Failure to Promptly and Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to conduct a prompt and thorough investigation into an injury of unknown origin for one resident. The resident, who was cognitively impaired and dependent for transfers, experienced a syncopal episode and was transferred to the ER. Later, the responsible party reported that EMS had not been gentle during the transfer, and the resident had cried out in pain. However, the facility's investigation lacked documentation of staff witness statements, did not include a record of conversation with the responsible party prior to the injury, and did not provide supporting documentation for the conclusion that the fractures were pathological. The investigation summary listed possible causes, including a pathological process, seizure activity, or rough EMS transfer, but did not contain comprehensive evidence or interviews to support these conclusions. The injury, specifically bilateral femoral neck fractures, was not identified until a later hospital visit for evaluation of seizure-like activity. Progress notes indicated facial bruising without a reported history of trauma, and imaging revealed the fractures may have been subacute. The administrator acknowledged that the investigation was incomplete, as staff were not asked for written statements and there was no information regarding events leading up to the hospital transfer or current hospital documentation. The responsible party also reported that the facility did not provide information about the cause of the injuries during care plan meetings.
Failure to Enter Verified Therapy Orders Resulting in Incomplete Medical Record
Penalty
Summary
A deficiency occurred when a verified exercise order for a resident was not entered into the electronic medical record, resulting in an incomplete clinical record. The order, provided by the resident's orthopedic physician, specified passive exercises for the lower extremities and active range of motion for the upper extremities due to the resident's non-weight bearing status. Although the nurse practitioner reviewed and signed off on the order, it was not transcribed into the computer system, and as a result, the ordered therapy services were not initiated. Review of the resident's physician orders for the relevant month confirmed the absence of documentation for the new exercises. The Director of Nursing confirmed that nurse practitioners are responsible for entering their own orders into the system and acknowledged that the resident's medical record did not accurately reflect all current orders. The facility administrator also verified that there was no policy in place for transcribing orders into the electronic system. The affected resident had a history of malignant neoplasm of the cervix, protein-calorie malnutrition, vitamin D deficiency, and bilateral femur fractures, and was cognitively impaired and dependent for transfers, with no ambulation.
Failure to Assess and Implement Safety Measures After Bed Rail Removal
Penalty
Summary
The facility failed to maintain a safe environment and provide adequate supervision and equipment to prevent accidents for one of four sampled residents. Staff removed the resident's bed rails without conducting a safety assessment, despite documentation indicating a history of falls from bed and a care plan that included the use of partial bed rails at all times. No assessment was completed to determine if the resident would be safe without the bed rails, and no alternative safety interventions were implemented at the time of removal. The resident, who had diagnoses including chronic obstructive pulmonary disease, muscle wasting and atrophy, repeated falls, and required assistance with personal care, was moderately cognitively impaired. During care, the resident rolled out of bed after the bed rails had been removed, sustaining a head laceration that required emergency room treatment, including x-rays and stitches. Staff interviews confirmed that the resident previously used the bed rails for assistance with turning and that their removal was based on a facility-wide policy change, not on an individualized assessment. Observations and interviews revealed that the resident was being assisted by a CNA at the time of the fall, who turned the resident and then reached for supplies, during which the resident rolled off the bed. The incident resulted in a significant injury, and it was confirmed by the DON and other staff that no side rail assessment was completed at the time of removal and no other safety measures were put in place to prevent injury after the bed rails were taken off.
Staffing Shortages Lead to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of residents, as evidenced by interviews with staff and residents, and a review of facility records. The Director of Nursing (DON) and other staff members reported significant staffing shortages, particularly during night shifts, which resulted in delayed responses to resident needs. The DON and Assistant Director of Nursing (ADON) were often required to cover shifts themselves due to high staff turnover and frequent call-ins, leading to exhaustion and a feeling of being overwhelmed. Residents reported long wait times for assistance, particularly at night, with some waiting over an hour for call lights to be answered. This delay in care was particularly concerning for residents who required assistance with personal care and transfers, as many residents needed two-person assistance. The facility's staffing grid confirmed that there were often only two CNAs working during night shifts, despite a census of fifty residents, many of whom required significant assistance. The facility's staffing issues were exacerbated by a lack of incentives for staff to work extra shifts, as bonuses had been reduced. The facility had several open CNA positions and was unable to retain new hires due to the heavy workload. Despite the DON's efforts to address staffing concerns, the Administrator believed that staffing was adequate and was unaware of resident complaints. The facility's failure to maintain sufficient staffing levels resulted in compromised resident care and unmet needs.
Misappropriation of Resident's Funds by CNA
Penalty
Summary
The facility failed to protect a resident's right to be free from misappropriation of property, as evidenced by the actions of a Certified Nursing Assistant (CNA). The CNA used the resident's debit card without permission to order food for herself and the resident, resulting in unauthorized charges. The resident initially allowed the CNA to use her debit card to order food due to a lack of access to a food ordering application. However, the CNA continued to use the card without the resident's consent, leading to multiple unauthorized transactions. The resident's husband discovered a pending charge on their bank account, which prompted an investigation. It was revealed that the CNA had saved the resident's debit card information on her phone and used it to make personal purchases. The CNA also asked the resident to buy her lunch, promising to pay her back, but failed to do so until confronted. The investigation uncovered additional unauthorized charges, including a subscription fee linked to the CNA's email address, which the resident did not approve. Interviews with staff and the resident confirmed the misappropriation of funds. The CNA admitted to using the resident's debit card and acknowledged that she knew it was against policy. Despite receiving training on abuse, neglect, and misappropriation of property, the CNA violated the resident's rights by misusing her financial information. The facility's policies clearly prohibit such actions, yet the CNA disregarded these guidelines, resulting in a breach of trust and financial exploitation of the resident.
Failure to Notify Resident's Representative of Medication Change
Penalty
Summary
The facility failed to notify the resident's representative (RR) of a change in medication for a resident who had been on Hydrocortisone and Desmopressin since 1980 due to Diabetes Insipidus. The Family Nurse Practitioner (FNP) at the facility discontinued Hydrocortisone based on a pharmacist's recommendation without informing the RR. The RR later explained the importance of the medication, leading to its reinstatement. The facility's policy required notifying the RR of any significant changes, including medication changes, but this protocol was not followed in this instance. Interviews with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and the FNP revealed that the decision to discontinue Hydrocortisone was made after a pharmacist highlighted a potential drug interaction. However, the ADON admitted that they failed to notify the RR about the medication change, assuming the FNP would address it during rounds the next day. The resident's progress notes and medication administration records confirmed the discontinuation and subsequent reinstatement of Hydrocortisone after the RR's intervention.
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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