Lamar Healthcare & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lumberton, Mississippi.
- Location
- 6428 Us Highway 11, Lumberton, Mississippi 39455
- CMS Provider Number
- 255338
- Inspections on file
- 19
- Latest survey
- April 2, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Lamar Healthcare & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with a stage 4 sacral pressure ulcer and severe cognitive impairment experienced significant weight loss while under orders for double portions, nutritional supplements, and weekly weights. Staff failed to consistently document meal intake and fluid intake, with numerous missing entries by CNAs and nurses over multiple weeks, and weights were obtained and entered inconsistently, leaving the RD with pending weights and incomplete data. The resident was observed to be very thin with visible bony prominences, and the responsible representative reported daily visits to help with meals due to concerns about poor intake and inconsistent weight monitoring. CNAs and an LPN acknowledged frequent meal refusals, variable intake, and that alternative food items were not routinely offered after refusals, while leadership confirmed there was no designated staff for weights and that delayed documentation contributed to delayed recognition of the resident’s significant weight loss.
A facility failed to manage pain for two residents. One resident with a heel wound and an order for scheduled Acetaminophen cried out in pain during wound care, but an LPN continued the treatment without assessing pain or giving the scheduled medication first. Another resident with an order for PRN Acetaminophen complained of leg and hip pain during care and afterward, but there was no documentation that pain medication was administered despite repeated complaints and physician notification.
The facility failed to ensure the DON did not serve as the RN Supervisor when the census was over 60 residents. The facility policy stated the DON may serve as charge nurse only when average daily occupancy is 60 or fewer, yet the DON was listed in that role on multiple days when census ranged from 88 to 94. The DON and Administrator both stated they were unaware of the restriction.
A resident with dementia and a regular diet order did not receive the approved alternate meal options when he disliked the meal served. Staff reported that the facility used an Always Available menu instead of the RD-approved alternate menu, and the dining room signage did not list alternate lunch or dinner options. The RD stated she was unaware the approved alternate menu was not being used and confirmed that the Always Available items alone may not provide equivalent nutritional value.
Incomplete Facility Assessment for Staffing Needs: The facility failed to maintain a comprehensive facility assessment to determine the number of qualified staff needed to meet resident needs, including sufficient RN coverage, affecting all residents. The assessment listed RN hours per resident day and average census, but did not break down direct care staffing needs by shift, document how resident acuity and care needs were used to set staffing levels, or include a recruitment/retention plan or contingency plan for licensed nurse coverage. The Administrator confirmed the assessment lacked specific staffing needs by shift and a documented recruitment/retention plan.
Failure to maintain an effective infection prevention and control program occurred when the DON, who also served as the Infection Preventionist, did not have sufficient time to complete infection surveillance, track and trend infections, or conduct infection control rounds for several months. Facility policy required surveillance, reporting review, and periodic IC rounds, but no infection surveillance logs or IC meeting minutes were available, and the DON stated she was occupied with staffing, scheduling, the med cart, and nursing supervisor duties.
Insufficient RN staffing and no designated charge nurse were identified. Facility records showed very limited RN hours per resident day, and the daily assignment sheets did not identify a charge nurse or RN supervisor for one shift. The DON stated the facility lacked enough RN staffing to complete weekly wound assessments for residents with pressure ulcers, relied on the outpatient wound clinic for those assessments, and had no weekly wound documentation with measurements or wound characteristics. She also reported she was performing multiple roles, including Infection Preventionist, staffing, scheduling, medication cart coverage, and nursing supervisor duties, and that staff simply knew the LPN or cart nurse was in charge rather than having a formally designated charge nurse.
The facility failed to conduct and document a thorough investigation into a fracture of unknown origin for a cognitively impaired resident with osteoporosis who developed right leg pain, was sent to the hospital and diagnosed with DVT, and later was found by mobile X-ray to have an acute nondisplaced subcapital femoral neck fracture. Although the facility’s policy required comprehensive investigation of injuries of unknown source, the investigation file lacked staff and resident interviews, witness statements, and an investigative summary identifying a possible cause. The SW reported she was not directed by the DON to perform interviews, the DON stated interviews had occurred but were not formally documented, and an LPN confirmed the sequence of events and that the cause and timing of the fracture could not be determined.
A resident with a history of a sacral pressure ulcer and severely impaired cognition had a wound care plan that was not updated to match current physician orders. The care plan continued to direct use of Plurogel and Polymem AG with an Allevyn border, while the active order required cleansing, application of Santyl as the primary dressing, followed by calcium alginate, gauze, and an Allevyn border, to be done daily and PRN. An RN reported she believed she had updated the care plan with the new order but confirmed on review that the plan still contained outdated wound care instructions, despite the Administrator’s expectation that care plans be revised as needed.
The facility failed to complete and document required weekly assessments, including measurements and characteristics, for a cognitively impaired resident with longstanding sacral pressure ulcers, despite physician orders for daily wound care and detailed assessments being performed only at outpatient wound care visits. Between two such visits, no in-house wound assessments were recorded. Staff, including an LPN and the DON, confirmed there was no dedicated wound nurse, that med cart nurses performed treatments, and that the facility relied on the outpatient provider for wound monitoring. The DON acknowledged the absence of weekly wound reports and cited insufficient RN staffing, while the RD reported having to request wound information due to lack of documented weekly assessments, and the resident’s representative voiced concern about whether the wound was being treated appropriately.
Failure to address a resident grievance about podiatry needs: A resident’s RR repeatedly voiced concern to staff for over a year that the resident needed a podiatry appt for thick, yellow, fungal-appearing toenails, but no appt was scheduled. An LPN, CNA, transportation staff, and the DON all acknowledged awareness of the request, and the resident had a BIMS score of 12 with hx of hemiplegia/hemiparesis following cerebral infarction.
Failure to Notify Resident Representatives of Hospital Transfers and Bed-Hold Rights: Two residents were transferred to the hospital, but the facility did not notify the resident representative or provide the bed-hold policy in a timely manner. One resident had CHF and was sent out for elevated BNP and tachycardia, and the record showed no transfer notice or bed-hold information was sent. For another resident, the bed-hold agreement was completed days after the transfer. The AR clerk confirmed the omissions, and the Administrator stated transfer notifications and bed-hold letters should be sent for all hospital transfers.
Failure to document and implement care plan monitoring interventions for medication side effects. Three residents had care plans that called for observation for side effects or bleeding related to psychotropic or anticoagulant medications, but the records showed no documentation that the monitoring occurred. The residents had diagnoses including Alzheimer’s disease, bipolar disorder, anxiety, depression, and chronic atrial fibrillation, and staff including an LPN, DON, RN, and administrator acknowledged the missing documentation.
Failure to provide ADL assistance with toenail care for a resident who required extensive ADL help. Staff observed the resident’s toenails to be thick, long, curved, and excessive in length, while the resident said they needed to be cut and was willing to see a podiatrist. CNAs reported they were expected to notify nursing of nail care needs, but no concerns had been reported, and the DON stated an earlier attempt to file the nails was refused with no follow-up completed.
Missing Oxygen-In-Use Signage: A resident receiving continuous oxygen via nasal cannula had no oxygen-in-use signage observed on or near the room door or above the bed, despite facility policy requiring signs at both locations. The resident had Alzheimer's disease, severe cognitive impairment, and a physician order for oxygen at 2 L via nasal cannula for shortness of breath. An LPN and the DON both confirmed that oxygen signage was required and that nursing staff were responsible for ensuring it was posted.
The facility failed to document monitoring for adverse consequences related to psychotropic and anticoagulant medications for three residents. One resident with Alzheimer’s disease received quetiapine and mirtazapine, another resident with bipolar disorder, anxiety, and depression received aripiprazole, alprazolam, and citalopram, and a third resident with chronic atrial fibrillation received apixaban. Staff stated they monitored for side effects, but the MAR and medical records contained no documentation of monitoring or related orders.
Two residents in a LTC facility did not receive timely incontinence care, compromising their dignity and well-being. One resident, cognitively intact and dependent on staff, was left in a soiled state during meals, while another with severe cognitive impairment experienced a delay in care despite a family member's request. Staff cited cross-contamination concerns for not providing care during meals, but this practice led to residents being left in soiled conditions, contrary to facility policies.
Two residents in an LTC facility did not receive timely incontinence care as per their care plans. One resident, with hemiplegia and cognitive intactness, was left in soiled bedding despite notifying a CNA of an accident. Another resident, with Alzheimer's and severe cognitive impairment, was not assisted promptly despite a family member's request. The DON confirmed the staff's failure to follow care plan interventions.
The facility did not have the Infection Preventionist (IP) present at any of the QAPI Committee meetings from July 2023 to June 2024, despite policy requirements. The QAPI Committee, which meets monthly, is responsible for overseeing the Quality Assurance and Performance Improvement Program. The absence of the IP was confirmed by the Administrator, who acknowledged the importance of the IP's role in enhancing healthcare quality for residents.
The facility failed to resolve repeated resident complaints about cold food served in their rooms over several months. During a Resident Council meeting, multiple residents expressed dissatisfaction with the temperature of food delivered to their rooms, although they had no issues with food served in the dining room. The Dietary Manager acknowledged the complaints, and the Administrator cited financial constraints as a reason for not purchasing heated carts, indicating a lack of effective action to address the issue.
The facility did not ensure residents were offered Influenza and Pneumonia vaccinations, as required by policy. Eight residents lacked documentation of being offered or receiving the Influenza Vaccine, and four residents had no records of being offered the Pneumonia Vaccine. The Infection Preventionist admitted to not following up on offering these vaccinations, despite the facility's policy mandates.
A facility failed to provide one-on-one activities for residents in the COVID-19 unit, affecting their psychosocial well-being. A resident, who enjoyed specific TV channels, was unable to change the channel herself and had not been asked about her preferences. The Activities Director had not assessed the resident's interests, and no documentation of activities was available. A CNA reported no observed activities or presence of the Activities department on the unit.
A resident reported that meals delivered to his room were consistently cold, a concern echoed by others during a Resident Council Meeting. Despite ongoing complaints, no improvements were made. The facility's administrator cited insufficient CMS funding for insulated carts as a contributing factor. The resident, with moderate cognitive impairment and medical conditions, stated he could only consume part of his meals due to the cold temperature.
Failure to Monitor and Support Nutritional Status Leading to Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary nutritional and hydration care and services to maintain a resident’s nutritional status, including failure to follow physician orders for monitoring and documentation. The resident was admitted with diagnoses including a stage 4 sacral pressure ulcer and had physician orders for double portions at lunch and supper, Mighty Shakes or equivalent supplements with each tray and at bedtime, Magic Cup supplements at lunch and supper, documentation of meal intake percentages at each meal, documentation of total fluid intake each shift, and weekly weights on Thursdays while the responsible party was present. The resident’s weight declined from 128 pounds to 94.4 pounds over approximately six months, with a documented 16.46% loss in about 30 days, yet the Significant Change MDS did not indicate a significant weight loss, and the RD’s February assessment noted the February weight as pending. Certified nurse aide documentation for February showed that meal intake amounts were not recorded for numerous meals, totaling 46 missing entries for that month. In March, the MAR showed that nurses failed to document meal intake percentages for 15 additional meals. The RD noted on 3/5 that the resident’s weight was 94 pounds with substantial percentage losses over 30, 90, and 180 days, and also identified inconsistencies in both weights and meal intake documentation, including an approximately 18‑pound loss in six days that she stated was not normal and could not be explained by refusal of some meals alone. The RD also reported that weights at the facility had been “hit and miss” for several months, and that when she documented weights as pending, it meant no weight had been entered. Observations and staff interviews further demonstrated failures in monitoring, evaluating, and implementing timely interventions related to nutrition and hydration. The resident was observed to have a thin appearance with visible bony prominences. The responsible representative reported daily visits to assist with meals due to concerns that the resident was not eating and that weights were not consistently monitored. CNAs reported that the resident frequently refused meals, could become combative, and that while staff encouraged eating, alternative food items were not routinely offered after refusals; on at least one observed occasion, the resident refused lunch and was not offered an alternative meal or substitute items. The LPN and DON confirmed ongoing weight loss, frequent meal refusals, inconsistent weight collection, lack of a designated staff member to obtain weights, and delays in entering weights into the record, which contributed to delayed identification of the resident’s significant weight loss.
Failure to Manage Pain During Wound Care and Resident Complaints
Penalty
Summary
The facility failed to ensure appropriate pain management for a resident who required wound care to the left heel. The resident had an order for Acetaminophen 500 mg three times daily for pain and a scheduled wound care treatment twice daily. On 3/31/26, the resident’s Acetaminophen was scheduled for 1:00 PM, but it was not documented as administered before wound care began. During the 1:45 PM wound care observation, the resident stated the treatment hurt, vocalized pain, and began crying, yet the LPN continued the procedure without stopping to assess pain or provide pain medication. The resident had a BIMS score of 3, indicating severely impaired cognition, and the DON stated staff were expected to assess pain prior to wound care and administer pain medication before treatment when pain was anticipated. The facility also failed to administer ordered pain medication for another resident who complained of pain. That resident had an order for Acetaminophen 325 mg every 8 hours as needed for pain. On 10/20/25, a CNA reported the resident was experiencing pain throughout the shift when being changed, and the nurse documented that the resident yelled out and would not move the leg. The physician was notified and an X-ray was ordered, but the progress note did not address how the resident’s pain was managed. Later that evening, the resident continued to complain of pain with movement of the right leg and was sent to the emergency department, with no documentation that pain medication had been administered. The resident continued to complain of pain to the right leg and hip the next day, and the record still did not address how pain was managed. The resident’s MAR showed pain was assessed each shift and documented as 0 on 10/20/25, and no pain medication, including Acetaminophen, was documented during the month. The resident had diagnoses including dementia and a BIMS score of 4, indicating severely impaired cognition. The DON confirmed there was no documentation that pain medication was administered despite an order being in place, and the Administrator stated the expectation was that nursing staff provide pain relief when residents complained of pain.
DON Served as RN Supervisor When Census Exceeded 60
Penalty
Summary
The facility failed to ensure the Director of Nursing (DON) did not function as the charge nurse when the census was over 60 residents. Review of the facility policy, Staffing, Sufficient and Competent Nursing, showed that the director of nursing services may serve as the charge nurse only when the average daily occupancy is 60 or fewer. Review of the daily assignment document showed the DON was listed as the RN Supervisor on 3/16/26 with a census of 88, on 3/17/26 with a census of 90, on 3/26/26 with a census of 94, and on 3/30/26 with a census of 93. During interview, the DON stated she was unaware she could not function in that role due to the census, and the Administrator stated she did not know the DON could not serve as RN Supervisor when the census was over 60 residents.
Failure to Provide Approved Alternate Meal Options
Penalty
Summary
The facility failed to provide alternate food options of similar nutritive value for one sampled resident, with the potential to affect all 89 residents in the facility. The facility policy stated that alternate foods and beverages are offered to residents who refuse the regular menu, and the facility’s Always Available Menu listed items such as grilled cheese, hamburgers, chicken tenders, soup/salad, half sandwiches, pimento cheese sandwiches, peanut butter and jelly sandwiches, and deli sandwiches. However, the facility’s Fall/Winter 2025/2026 Week 1 Alternates and Modified Items menu contained full meal alternatives such as sliced turkey, steak fingers, and smoked sausage, and did not include the items on the Always Available Menu, even though the alternate menu was signed by the RD. Resident #12 was admitted with unspecified dementia and had a regular diet order. During observation, he stated that he does not always like what is served, and a CNA reported that when he did not like chicken alfredo, the facility did not offer alternate meals but instead allowed residents to get an item from the Always Available menu. The dining room signage listed breakfast, lunch, and dinner menus but did not list an alternative lunch or dinner menu. The Dietary Manager stated the facility did not offer alternative meals for lunch or dinner because it had an Always Available menu, while the RD stated she was not aware that the approved alternate menu was not being prepared and offered and confirmed that items from the Always Available menu alone may not provide equivalent nutritional value.
Incomplete Facility Assessment for Staffing Needs
Penalty
Summary
The facility failed to conduct and maintain a comprehensive facility assessment to determine the appropriate number of qualified staff needed to meet resident needs, including sufficient licensed nursing staff coverage, affecting all 89 residents in the facility. The facility’s policy stated that the assessment is used to inform staffing decisions, ensure enough staff with appropriate competencies and skill sets to meet resident needs identified through resident assessments and plans of care, and develop and maintain a direct-care staff recruitment and retention plan. Record review of the facility assessment showed Staffing Hours per Resident Day data for October 1 through December 31, 2025, with RN hours documented at 0.173 hours per resident per day, or about 10 minutes of RN time per resident per day. Based on an average census of 88.6 residents, this equaled 15.3 RN hours per day. The assessment did not include a breakdown of the number and type of direct care staff needed by shift, did not document how resident acuity and care needs were used to determine staffing levels, and did not include a recruitment and retention plan or a contingency plan to ensure licensed nurse coverage. During interview, the Administrator stated the facility considers census, staffing hours, and resident needs when compiling the assessment, and confirmed that the assessment did not document specific staffing needs by shift and did not contain a documented recruitment or retention plan.
Failure to Maintain Infection Prevention and Control Program
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program when the designated Infection Preventionist, who was also the Director of Nursing (DON), did not have sufficient time to complete infection prevention and control duties. As a result, infection surveillance was not conducted, infections were not tracked or trended, and infection control rounds were not performed for three of five months reviewed. The deficiency had the potential to affect all 89 residents in the facility. Facility policy required the Infection Preventionist to identify infections and trends, determine whether infections were reportable, and collect data when transmission-based precautions or other preventative measures were used. Another policy required the Infection Preventionists to conduct unannounced periodic infection control rounds at least quarterly and complete the infection control checklist during each round. However, the facility had no infection surveillance logs available to review and no infection control meeting minutes documenting that infection control meetings were conducted for oversight. During interview, the DON stated she also served as the Infection Preventionist and was responsible for staffing, scheduling, and daily operations, and that she had not had time to complete surveillance, track infections, or conduct rounds because she was working the medication cart or functioning as the nursing supervisor. The Administrator stated she believed the DON had sufficient time to complete infection prevention duties in addition to her other responsibilities.
Insufficient RN Staffing and No Designated Charge Nurse
Penalty
Summary
The facility failed to ensure RN staffing was adequate to meet resident needs and failed to designate a licensed nurse as the charge nurse for each shift. Facility policy stated that sufficient nursing staff would be provided and that a licensed nurse would be designated as charge nurse on each shift, but the facility assessment showed RN staffing at 0.173 hours per resident per day, or about 10 minutes of RN time per resident per day, based on an average census of 88.6 residents. The facility’s daily assignments showed that on 3/30/26 there was no designated Charge Nurse or RN Supervisor for the 6 PM or 6 AM shift. During interviews, the DON stated the facility did not have sufficient RN staffing to complete weekly wound assessments for residents with pressure ulcers and relied on the outpatient wound clinic to complete those assessments. She also stated there was no weekly wound documentation available that included measurements or wound characteristics for residents with wounds. The DON further reported she was serving as Infection Preventionist and was responsible for staffing, scheduling, and daily operations, but had not had time for infection surveillance, infection tracking, or infection control rounds for several months because she was working the medication cart or functioning as the nursing supervisor. She confirmed that staff knew the LPN or cart nurse was in charge, but there was no designated charge nurse with specific responsibilities such as staff supervision, emergency coordination, physician liaison, and direct resident care.
Failure to Thoroughly Investigate and Document Fracture of Unknown Origin
Penalty
Summary
The facility failed to conduct and document a thorough investigation into a fracture of unknown origin for one resident, as required by its Abuse Investigation and Reporting policy. The policy, revised July 2017, required that all injuries of unknown source be thoroughly investigated, including review of all events leading up to the incident and documentation of investigative results on approved forms. For this resident, who had diagnoses including osteoporosis and dementia and a BIMS score of 4 indicating severely impaired cognition, records showed that the resident complained of right lower extremity pain and was sent to the hospital, where a DVT was diagnosed. After returning to the facility, the resident continued to complain of right leg and hip pain, and a mobile X-ray revealed an acute nondisplaced subcapital femoral neck fracture of the right hip. The investigation file for this injury did not contain evidence of staff or resident interviews, witness statements, or a documented investigative summary identifying the possible cause of the fracture. The social worker stated she was not directed by the DON to conduct interviews for this incident and could not explain why interviews were not completed. The DON reported that the resident and staff had been interviewed and that the resident had reportedly said he fell but was unsure of details; however, the DON was unsure if any documentation existed to support these interviews and later confirmed that interviews were not formally documented and that the policy had not been followed. An LPN confirmed she was working when the resident first complained of pain, described the sequence of physician notification, X-ray orders, hospital transfer, and subsequent fracture diagnosis, and stated the facility was unable to determine how or when the fracture occurred. The Administrator acknowledged that staff and resident interviews related to the injury of unknown origin were expected to be completed and documented, and confirmed that such documentation was not present.
Failure to Update Wound Care Plan to Reflect Current Physician Orders
Penalty
Summary
The deficiency involves the facility’s failure to revise a comprehensive care plan to reflect current physician orders for a resident with impaired skin integrity. Record review showed that the resident had a care plan for a Stage III sacral wound, described as a healing Stage IV wound, with an intervention initiated on 1/28/26 directing staff to remove the old dressing, cleanse with wound cleanser, apply Plurogel, use Polymem AG (alginate) as the primary dressing, and Allevyn border as the secondary dressing, to be done daily and PRN. This care plan content was inconsistent with the active physician order dated 2/19/26, which specified removing the old dressing, cleansing with wound cleaner, applying Santyl to the sacral wound as the primary dressing, then applying calcium alginate, gauze, and covering with an Allevyn border dressing, to be done daily and PRN. The resident was admitted with a diagnosis including a Stage 4 pressure ulcer of the sacral region, and a Significant Change MDS with an ARD of 01/30/26 documented a BIMS score of 04, indicating severely impaired cognition, and one unhealed Stage 3 pressure ulcer. During interview, an RN stated she updates care plans with each new order and believed she had done so for this resident’s wound care, but upon reviewing the physician orders and care plan, she confirmed the care plan still reflected outdated wound care orders. In a separate interview, the Administrator stated she expects resident care plans to be revised as needed.
Failure to Complete and Document Weekly Pressure Ulcer Assessments
Penalty
Summary
The facility failed to provide weekly pressure ulcer assessments, including wound dimensions and characteristics, for a resident with a longstanding sacral pressure ulcer, contrary to its own policy requiring documentation of location, stage, length, width, depth, and presence of exudate or necrotic tissue. The resident was admitted with a diagnosis of a stage 4 sacral pressure ulcer and later had an MDS indicating unhealed pressure ulcers, including a stage 3 ulcer, and severely impaired cognition with a BIMS score of 4. Physician orders directed daily wound care to the sacral wound, and outpatient wound care visits on 3/10/26 and 3/31/26 documented complete wound assessments, including measurements, drainage, and wound characteristics, with impressions that the wound had improved. However, there was no facility documentation of any wound assessment between these outpatient visits. During observations, the resident was seen in bed on an air mattress with a positioning wedge, and the resident’s responsible representative expressed concern and uncertainty about whether the sacral wound was being treated appropriately. Interviews with an LPN and the DON confirmed that the facility did not have a dedicated wound care nurse and that medication cart nurses performed daily treatments while the facility relied on the outpatient wound care provider for wound assessments and monitoring. The DON acknowledged that there were no weekly wound reports with measurements or descriptive assessments available and attributed this to insufficient RN staffing to complete weekly wound assessments. The RD also reported having to request wound information from the DON because weekly wound reports were not available in the medical record. The Administrator stated an expectation that wound assessments be completed as required.
Failure to Address Resident Grievance About Podiatry Needs
Penalty
Summary
The facility failed to ensure that one resident’s verbalized grievance was addressed and resolved regarding the resident’s toenails and need for a podiatry appointment. The resident’s Resident Representative stated she had been voicing concerns for over a year to facility staff, including a CNA, that the resident needed podiatry services, but no appointment had been arranged. During observation, the resident’s toenails were noted to be thick and yellow-discolored on both feet, and the RR reiterated her concern that the issue had not been addressed. Staff interviews confirmed awareness of the concern. An LPN reported she knew the resident’s family had requested a podiatry appointment and described the toenails as thick and fungal in nature. A CNA stated the RR brought the concern to her in late February 2026 and that the resident had thick, yellow toenails. A transportation staff member responsible for scheduling appointments confirmed she knew the RR had requested podiatry services but that no appointment had been scheduled. The DON stated that once staff became aware of the request, nursing staff should have obtained a physician’s order and scheduled a podiatry visit. The resident was admitted on 5/24/24 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, and the MDS dated 2/5/26 showed a BIMS score of 12, indicating moderately impaired cognition.
Failure to Notify Resident Representatives of Hospital Transfers and Bed-Hold Rights
Penalty
Summary
The facility failed to notify the resident representative of a hospital transfer and failed to provide the bed-hold policy for two residents sampled for hospitalization and closed record review. Facility policy stated that notice of transfer is to be provided to the resident and representative as soon as practicable before transfer, and that notice of facility bed-hold policies is to be provided within 24 hours of an emergency transfer in a form and manner the resident can understand. For one resident, the record showed a physician ordered transfer to a local hospital for elevated BNP and tachycardia, and the medical record contained no evidence that the resident representative was notified or that the bed-hold policy was provided at the time of transfer or within the required timeframe. For another resident, the record showed transfer to a short-term general hospital with return anticipated, but the private pay bed-holding agreement was completed six days after the transfer. During interview, the Accounts Receivable Clerk confirmed she did not send the transfer notice or bed-hold notice for the first resident and acknowledged the bed-hold notice for the second resident was sent late; the Administrator stated that all hospital transfer notifications are to be sent to the resident representative regardless of payer source.
Failure to Document and Implement Care Plan Monitoring Interventions
Penalty
Summary
The facility failed to implement comprehensive care plan interventions with measurable objectives and timetables for three sampled residents. The facility policy for comprehensive person-centered care plans stated that care plans should include measurable objectives and timeframes and reflect recognized standards of practice for problem areas and conditions. Survey review found that the care plans for the affected residents included interventions to observe for medication side effects, but the records did not show documentation that those interventions were actually carried out. For one resident with Alzheimer’s disease who was receiving quetiapine and mirtazapine, the care plan included monitoring for side effects such as dizziness, drowsiness, and changes in cognition. The resident’s record showed active orders for the medications, but there were no orders for side-effect monitoring and no documentation in the MAR or medical record that monitoring occurred. An LPN confirmed there was no documented evidence of monitoring for the medication side effects. For another resident with bipolar disorder, depression, anxiety, and other psychoactive substance use, the care plan included observing for side effects of psychotropic medications such as citalopram, alprazolam, and aripiprazole. The record showed active orders for antipsychotic, antianxiety, and antidepressant medications, but there were no orders for side-effect monitoring and no documentation in the MAR or medical record that monitoring occurred. For a third resident with chronic atrial fibrillation receiving apixaban, the care plan included observing for signs and symptoms of bleeding, but the record showed no documentation in the MAR or medical record that bleeding monitoring occurred. The DON, RN, and administrator all acknowledged that documentation of the monitoring interventions was not present.
Failure to Provide Toenail Care
Penalty
Summary
The facility failed to provide assistance with ADLs related to toenail care for one resident who required extensive assistance with ADLs except feeding and received staff help with bed baths. During observation, the resident’s toenails were noted to be thick, long, curved, and excessive in length, and the resident stated the toenails needed to be cut and was unsure how long they had been that way. The resident had a BIMS score of 15, indicating cognitive intactness, and had diagnoses including encounter for surgical aftercare following surgery on the genitourinary system. Facility staff reported that CNAs were expected to notify nursing staff when nail care was needed, but no concerns had been reported for this resident’s toenails. An LPN stated the facility did not have an in-house podiatrist and residents had to be sent out for podiatry services, but she had not been notified of any toenail concerns. The DON reported she had attempted to file the resident’s toenails months earlier, but the resident refused, and no follow-up was completed; she was unsure whether a podiatry appointment had ever been scheduled. Later observation showed the toenails remained long and thick, and the resident stated something needed to be done and was willing to see a podiatrist.
Missing Oxygen-In-Use Signage
Penalty
Summary
The facility failed to ensure required cautionary signage was in place for a resident receiving oxygen therapy. The facility policy for Oxygen Administration stated that no smoking/oxygen in use signs were to be available and that an oxygen in use sign was to be placed on the outside of the room entrance door and in a designated place on or over the resident's bed. During observation, the resident was in bed receiving oxygen at 2 liters per minute via nasal cannula, and no oxygen-in-use signage was observed on or near the resident's door or above the bed. Resident #45 had been admitted with diagnoses including Alzheimer's Disease and had a BIMS score of 03, indicating severe cognitive impairment. The resident's MDS showed oxygen therapy was received, and the physician's order directed oxygen at 2 liters via nasal cannula every shift for shortness of breath. An LPN confirmed the resident had been on continuous oxygen therapy since January 2026 and stated that oxygen-in-use signage is required on the doors of residents receiving oxygen. The DON also stated that oxygen signage was expected to be posted on the doors for residents receiving oxygen therapy and confirmed nursing staff were responsible for ensuring the cautionary signage was present.
Failure to Document Monitoring for Psychotropic and Anticoagulant Medication Side Effects
Penalty
Summary
The facility failed to ensure appropriate monitoring and documentation of potential adverse consequences for psychotropic and high-risk medications for three residents. The deficiency involved a review of the facility policy on adverse consequences and medication errors, which stated that residents receiving medication are monitored for adverse consequences and that the interdisciplinary team monitors medication usage to prevent and detect medication-related problems such as adverse drug reactions and side effects. For Resident #3, who had diagnoses including Alzheimer’s disease and a BIMS score of 6 indicating severely impaired cognition, the record showed active orders for quetiapine and mirtazapine. During interview, an LPN stated the resident had dementia and confusion but no known side effects from antipsychotic medications, and confirmed there was no documented evidence of monitoring for medication side effects. The medical record, including the MAR, contained no documentation that the resident was monitored for side effects, and there were no orders for such monitoring. For Resident #6, who had diagnoses including bipolar disorder, depression, anxiety disorder, and other psychoactive substance use with psychoactive substance-induced mood disorder, the record showed active orders for aripiprazole, alprazolam, and citalopram, along with an additional alprazolam order. An LPN stated the resident had not had adverse side effects to prescribed psychotropic medications and confirmed there was no place in the record to document monitoring for side effects. The MAR and medical record contained no documentation of monitoring for side effects of antipsychotic, antianxiety, or antidepressant medications. For Resident #25, who had chronic atrial fibrillation and a BIMS score of 12 indicating moderately impaired cognition, the record showed an active order for apixaban (Eliquis). The resident stated she bruises easily, and an LPN reported the resident was monitored for side effects but was not aware of any documentation. The medical record, including the MAR, contained no documentation to monitor for bleeding or other side effects of anticoagulant medication.
Failure to Provide Timely Incontinence Care and Maintain Resident Dignity
Penalty
Summary
The facility failed to ensure the dignity and timely incontinence care for two residents, leading to a deficiency in meeting their physical, mental, or psychosocial needs. Resident #8, who was cognitively intact and dependent on staff for toileting hygiene, was observed lying in bed with a strong odor of urine and feces. Despite informing a CNA earlier in the morning about her incontinence, she did not receive assistance until much later in the day. The resident expressed feelings of humiliation and degradation as she was left in a soiled state during meal times, which was against the facility's policy of maintaining resident dignity. Resident #34, who had a severely impaired cognition due to Alzheimer's Disease, also experienced a delay in receiving incontinence care. A family member had informed a nurse about the resident's need for assistance, but the care was not provided before lunch. The resident was later found with a heavily saturated brief, and the staff failed to follow up on the initial request for care. The CNAs and LPN involved did not ensure the resident's needs were met, and there was a lack of communication and follow-up regarding the resident's refusal to be cleaned initially. The facility's policies on routine resident checks and dignity were not adhered to, as evidenced by the staff's failure to provide timely incontinence care. The CNAs were instructed not to clean residents during meal times to prevent cross-contamination, but this led to residents being left in soiled conditions. The DON and RN confirmed that residents should be checked every two hours and cleaned before meals, highlighting a gap between policy and practice in the facility.
Failure to Implement Incontinence Care Plans
Penalty
Summary
The facility failed to implement comprehensive care plan interventions for incontinence care for two residents. Resident #8, who was admitted with hemiplegia and had a BIMS score indicating cognitive intactness, was found lying in bed with a strong odor of urine and feces. Despite informing a CNA earlier in the morning about an accident, the resident did not receive incontinence care until much later in the day. The CNAs responsible for her care stated they were occupied with rounds for other residents and could not attend to her needs promptly. The Director of Nursing confirmed that the CNAs did not follow the care plan, which required checking on residents every two hours and providing necessary care before lunch. Resident #34, diagnosed with Alzheimer's Disease and having a severely impaired cognition, also did not receive timely incontinence care. A family member informed an RN about the resident's need for assistance, but the resident continued to wear a heavily saturated brief hours later. The Director of Nursing confirmed the staff's failure to implement the care plan intervention for perineal care as needed. The RN acknowledged that the care plan was intended to guide the resident's care and expected staff to provide timely incontinence and perineal care.
Infection Preventionist Absence in QAPI Meetings
Penalty
Summary
The facility failed to ensure the presence of the Infection Preventionist (IP) in the Quality Assurance and Performance Improvement (QAPI) Committee meetings for a full year, from July 2023 through June 2024. According to the facility's policy, the QAPI Committee, which is responsible for overseeing and implementing the Quality Assurance and Performance Improvement Program, must include the IP as a member. The committee is required to meet at least quarterly, but the facility's records showed that the IP was absent from all 12 meetings held during the specified period. During an interview, the Administrator acknowledged that the QAPI committee meets monthly and confirmed the absence of the IP from these meetings. The Administrator recognized the importance of the IP's presence in improving the quality of healthcare for residents, indicating an awareness of the deficiency.
Failure to Address Resident Complaints of Cold Food
Penalty
Summary
The facility failed to address repeated concerns from residents regarding the temperature of food served in their rooms over a period of three months. During a Resident Council meeting, multiple residents expressed dissatisfaction with the cold food delivered to their rooms, although they did not have issues with food served in the dining room. Specific residents mentioned that eggs and other foods were consistently cold, and the council had raised these concerns with staff multiple times without any improvement. The grievance log minutes from January, April, and May 2024 documented these complaints, with residents suggesting the use of heated carts for food transport, but there was no evidence of any attempts by the facility to resolve the issue. An observation of the kitchen revealed that food was delivered using open metal carts with a clear plastic cover, and the Dietary Manager confirmed that these carts were used for food delivery to the halls. The Dietary Manager acknowledged awareness of the complaints but stated that food temperatures were only checked at the holding table in the kitchen before plating. The facility Administrator admitted awareness of the cold food concerns and mentioned discussing alternative serving orders with the Dietary Manager. However, the Administrator cited financial constraints as a reason for not purchasing insulated or heated carts, indicating a lack of effective action to address the residents' grievances.
Failure to Offer Vaccinations to Residents
Penalty
Summary
The facility failed to ensure that residents were offered Influenza and Pneumonia vaccinations, as evidenced by the lack of documentation indicating that vaccinations were either offered or administered to eligible residents. Specifically, eight out of the 17 sampled residents did not have records showing they were offered or received the Influenza Vaccine in 2023. Additionally, there was no documentation that the Pneumonia Vaccine was offered to four residents, nor was there any record of these residents having previously received the vaccine. The facility's policies require that residents admitted between October 1st and March 31st be offered the Influenza Vaccine within five working days of admission, and that residents be assessed for eligibility for the Pneumococcal Vaccine series upon admission, with the vaccine offered within thirty days if appropriate. However, the Infection Preventionist acknowledged that she had not followed up to offer the vaccinations to many residents, despite the policy requirements. This oversight was confirmed through staff interviews and record reviews, highlighting a failure in the facility's vaccination protocol.
Failure to Provide Individualized Activities for Isolated Residents
Penalty
Summary
The facility failed to provide one-on-one activities for residents on isolation in the COVID-19 unit, specifically for one resident, which had the potential to affect all residents on the unit. The facility's policy on activity programs, revised in June 2018, mandates that activities should be based on comprehensive resident-centered assessments and preferences. However, during observations and interviews, it was found that a resident in the COVID-19 unit, who enjoyed watching hunting or auto channels on TV, was unable to change the channel herself and had not been asked about her activity preferences since being in the unit. The Activities Director, who had been in the position for a few months, admitted that the resident had not yet been assessed for her interests and preferences, and there was no documentation available to confirm that one-on-one activities had been conducted with her. Further interviews revealed that the Certified Nurse Aide (CNA) working on the COVID-19 unit had not observed any in-room activities for the residents and had not seen anyone from the Activities department on the unit. The resident, admitted to the facility in 2018, had a BIMS score indicating she was cognitively intact and expressed that it was very important for her to engage in her favorite activities. Despite this, the facility failed to provide the necessary individualized activities, as required by their policy, for residents in isolation, leading to a deficiency in meeting the psychosocial needs of the residents.
Failure to Serve Meals at Appropriate Temperature
Penalty
Summary
The facility failed to ensure that meals were served at a palatable and satisfactory temperature for one of the sampled residents. Resident #70, who had been at the facility for three weeks, reported that meals delivered to his room were consistently cold. This issue was corroborated during a Resident Council Meeting, where multiple residents, including Resident #70, expressed ongoing dissatisfaction with the temperature of their meals. Despite repeated complaints over several months, no improvements were noted in the food temperatures. The facility's policy on meal service emphasized the importance of delivering food promptly to ensure it is safe, palatable, and served at the appropriate temperature. However, the facility administrator acknowledged that the lack of insulated carts for food delivery contributed to the problem, citing insufficient funding from CMS as a reason. Resident #70, who has moderate cognitive impairment and medical conditions such as hypertension and hyperlipidemia, stated that he could only consume three-fourths of his meals due to the cold temperature, impacting his overall meal intake.
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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