Landmark Of Desoto
Inspection history, citations, penalties and survey trends for this long-term care facility in Horn Lake, Mississippi.
- Location
- 3068 Nail Road West, Horn Lake, Mississippi 38637
- CMS Provider Number
- 255281
- Inspections on file
- 19
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Landmark Of Desoto during CMS and state inspections, most recent first.
The facility failed to obtain informed consent before starting psychotropic medications for 5 residents reviewed. Orders for antipsychotic, psychoactive, and related medications were initiated before resident or RR consent was completed, including cases involving residents with dementia, schizophrenia, anxiety, and depression. The DON confirmed several consents were signed after treatment began and stated the process was delayed because the medical director did not complete the forms, and the consents did not represent true informed consent.
The facility failed to ensure physician review of pharmacy GDR recommendations and failed to include stop dates on PRN psychotropic orders for several residents. A resident had PRN Klonopin without a stop date, two PRN lorazepam orders also lacked stop dates, and pharmacy recommendations for dose reduction of psychotropics for two cognitively intact residents remained unaddressed. The DON confirmed the unaddressed recommendations and missing stop dates.
Medication Error Rate Exceeded Allowed Threshold: The facility’s medication error rate was 18.18%, above the required 5% limit. An LPN gave one resident’s scheduled AM medications early, outside the allowed one-hour window, and acknowledged it was a medication error. The same LPN also failed to administer another resident’s scheduled prednisone because the medication was out, and the DON confirmed the resident should not miss a dose and that the medication was kept in the emergency drug kit.
A resident’s call light was not kept within reach while she was lying in bed with the bed lowered and a fall mat beside it. The resident said she knew to push the red button for help, and an LPN confirmed she was a fall risk and had recently returned from the hospital after a UTI. The call light was found between the bed and the wall, and a CNA stated it had been dislodged during care and not placed back within reach. The resident had COPD and moderately impaired cognition.
Inaccurate MDS Bladder Assessment: A resident’s MDS failed to document an indwelling urinary catheter in Section H even though observation and the TAR showed a catheter and catheter bag order in place. The MDS nurse confirmed the assessment error, and the resident had diagnoses including diverticulosis and a stage 3 sacral pressure ulcer, with BIMS indicating cognitive intactness.
IDT care plan review was not fully documented for a resident with ESRD who was cognitively intact. Care plan review forms showed only the SW Director signed the meetings, while the resident rep attended by phone. Staff stated the SW schedules the meetings and the IDT includes MDS, therapy, Social Services, Activities, and Dietary, but the record did not show the full IDT reviewed and revised the resident’s comprehensive care plan as required.
A resident with hemiplegia, hemiparesis, and a contracted right hand was observed without his ordered right wrist splint in place, even though the splint was supposed to be applied for 4 hours daily. RN staff said they were unaware of the order and the TAR did not reflect it, while the DON confirmed the order was not entered correctly and the splint was not being applied as ordered.
Improper Foley Catheter Drainage Bag Positioning: A resident with a Foley catheter had the drainage bag attached to the lower bed frame, but during catheter care the CNA and RN placed the bag in the bed with the resident, causing urine backflow into the tubing. The RN confirmed the bag was not positioned to allow proper drainage and stated the urine could reflux and increase the risk for a UTI.
Improper Storage and Dating of Insulin on Medication Cart: An LPN observed several open insulin products on a medication cart that were either undated or beyond the manufacturer’s 28-day room-temperature limit, including Novolog, Humalog, Insulin Aspart, and a Humalog KwikPen for multiple residents. The facility policy required storage per manufacturer specifications, and the LPN stated undated insulin could not be verified as safe to administer; the DON confirmed insulin on carts should be labeled with an open date and kept within the 28-day use period.
The facility failed to properly disinfect a glucometer after use when an LPN wiped the front and back of the device and stored it immediately instead of keeping it wet for the required contact time. The facility also failed to place a resident with an ESBL urine culture result on contact precautions; the DON and an LPN confirmed the diagnosis and that precautions were not in place. The resident had COPD listed among the admission diagnoses.
The facility failed to develop comprehensive care plans for two residents with pressure ulcers. One resident developed an unstageable ulcer on the right fourth ring finger due to a hand contracture, and another resident had a new pressure wound on the right Achilles area. Interviews with staff confirmed the absence of care plans addressing these issues, highlighting a deficiency in care planning for pressure ulcer management.
Two residents in the facility developed pressure ulcers due to inadequate preventive measures and treatment. One resident developed an ulcer on the finger due to a hand contracture, with no pressure relief devices in place before the ulcer appeared. Another resident developed a pressure wound on the Achilles area from an immobilizer, with no daily skin assessments or physician orders for the device. Staff interviews confirmed the lack of preventive measures and monitoring, leading to avoidable wounds.
The facility did not submit accurate direct care staffing information to CMS for Q3 FY 2024. The absence of a policy for PBJ submission and the reassignment of administrative staff to direct care without proper reporting contributed to the error. The Administrator acknowledged the issue, noting the corporate office's role in data compilation.
A resident was left uncovered and visible from the hallway, exposing their incontinence brief and PEG tube. Despite the facility's policy on dignity and respect, the privacy curtain was not used, as confirmed by an LPN and the DON. The resident had a diagnosis of Cerebral Infarction.
A facility failed to honor a resident's right to make healthcare decisions regarding CPR. The resident, who was cognitively capable, was not consulted about her advanced directives or code status. Instead, a family member signed the consent without the resident's involvement. Interviews with staff confirmed the oversight, acknowledging that the resident should have been allowed to sign her consent upon admission.
A resident with neuromuscular dysfunction of the bladder and an indwelling urinary catheter received improper catheter care from a CNA, who used the same washcloth for cleaning and rinsing without changing gloves, leading to cross-contamination. The facility's policy required a clean washcloth for rinsing to prevent infections, which was not followed.
The facility failed to reconcile controlled medications, specifically Lorazepam, in one of its narcotic storage areas. The Lorazepam, part of the Emergency Drug Kit, was not counted every shift as required by facility policy. Interviews revealed that the medication was not included in the narcotic count book, raising concerns about potential narcotic diversion. The DON confirmed the oversight.
A resident was found with medications left at her bedside, including sore throat spray and lubricating eye drops, without a physician's order. The resident, who was moderately cognitively impaired, used these medications without staff monitoring. An LPN confirmed the situation, and the facility's administrator acknowledged that medications should be secured, as per facility policy.
Informed consent for psychotropic medications not obtained before treatment
Penalty
Summary
The facility failed to obtain informed consent before starting psychotropic medications for 5 of 5 residents reviewed for unnecessary medications. Facility policy titled Psychotropic Medications stated that consent for anti-psychotic, psychoactive, or neuroleptic medication treatment must be completed for a new order or an increased dose, with the prescribing physician or medical director completing the section on indications, diagnosis, risks, benefits, alternatives, and course of therapy, and the resident or resident representative completing the consent section. For Resident #1, orders for Klonopin for agitation and combativeness and Risperdal for generalized anxiety disorder were initiated before the resident representative gave phone consent. Resident #1 had diagnoses including encounter for attention to gastrostomy and generalized anxiety disorder, and the MDS showed moderately impaired cognitive skills for daily decision making. For Resident #3, orders for Mirtazapine, Trazodone, and later Risperdal were already in place before the resident representative signed the consent form. Resident #3 had diagnoses including dementia and encephalopathy, and the MDS showed a BIMS score of 06, indicating severe cognitive deficits. For Resident #6, active orders included Lorazepam, Donepezil, and Olanzapine, but the consent form was signed after the medications had already started. The DON stated the consent form available was dated after initiation and explained that the process had been delayed because the medical director had left and did not complete the forms. For Resident #12, Haloperidol Decanoate was started before the resident representative signed consent, and the DON confirmed the consent was signed after treatment began. For Resident #38, Duloxetine had been ordered long before the resident signed the consent acknowledging risks and benefits, and the DON confirmed the consents were not provided to residents and/or families in advance of treatment and did not represent true informed consent. Resident #12 had diagnoses including unspecified dementia and schizophrenia with a BIMS score of 15, and Resident #38 had major depressive disorder with a BIMS score of 15.
Unaddressed psychotropic medication reviews and missing PRN stop dates
Penalty
Summary
The facility failed to ensure that the physician reviewed and responded to pharmacy recommendations for gradual dose reduction (GDR) and failed to ensure that as-needed (PRN) psychotropic medication orders included stop dates for four residents. Facility policy stated that GDRs were to be completed for psychotropic medications and that PRN psychotropic medications were limited to 14 days unless the physician documented a rationale to extend them. Survey review found that the medical director had pharmacy recommendations in his folder, but they had not been addressed or returned, and the DON confirmed the recommendations remained unaddressed. For Resident #1, the order summary showed Klonopin 0.5 mg via PEG tube every 8 hours PRN for agitation and combativeness without a stop date. The pharmacy consultant had notified the provider the previous month, but the order remained unaddressed. The DON confirmed the PRN Klonopin order should have had a stop date after 14 days and then been re-evaluated. Resident #1 was admitted with diagnoses including attention to gastrostomy and generalized anxiety disorder, and the MDS showed moderately impaired cognitive skills for daily decision making. For Resident #6, two PRN lorazepam oral concentrate orders for anxiety had no stop dates, and the DON confirmed both orders lacked stop dates. The DON stated the hospice nurse and family did not want the medication discontinued. A pharmacy recommendation related to Ativan 0.5 mg daily had been issued, but there was no evidence the physician reviewed it. For Resident #12, the last completed psychoactive GDR was dated 02/11/25, and a consultant pharmacist recommendation to consider dose reductions for trazodone and Haldol was not addressed. For Resident #38, a consultant pharmacist recommendation to consider a dose reduction for duloxetine remained unaddressed. Resident #12 and Resident #38 were both documented as cognitively intact on their MDS assessments.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to keep the medication error rate at 5 percent or less, with a reported error rate of 18.18 percent based on six errors out of thirty-three medication opportunities. Facility policy required medications to be administered no more than one hour before or after the ordered time and required verification of the physician’s order against the MAR before administration. During review, Resident #17’s MAR showed several medications scheduled for 9:00 AM, including lisinopril, multivitamin liquid, hydroxyzine, metformin, and levetiracetam solution. An LPN stated she had already given the resident’s 9:00 AM medications before 7:35 AM and acknowledged this was a medication error and did not follow nursing standards of practice. Resident #17 had diagnoses including hemiplegia and hemiparesis following cerebral infarction, and the MDS indicated severely impaired cognitive skills for daily decision making. During observation of medication pass, the same LPN prepared Resident #43’s medications and stated the resident was out of prednisone 5 mg tablets, so the medication was not administered. She said she would write it on her list to be faxed to the pharmacy and reordered, and confirmed it would not be available that day. Resident #43’s MAR showed prednisone ordered daily at 8:00 AM for bronchitis, and the LPN later acknowledged the resident could have respiratory changes by missing a dose. The DON stated prednisone was kept in the emergency drug kit, that she had not been notified the resident was out of the medication, and that the order could have been faxed to the pharmacy or called to a backup pharmacy. Resident #43 had diagnoses including COPD with acute exacerbation and bronchitis, and the MDS showed a BIMS score of 15, indicating cognitive intactness.
Call Light Not Within Reach
Penalty
Summary
The facility failed to keep the call light accessible for Resident #30, who was observed lying in bed with the bed in the lowest position and a fall mat on the floor beside the bed. A sign above the bed reminded the resident to call for assistance, but the call light was not within reach. During the observation, the resident stated that she knew to push the red button if she needed help, and the resident was noted to be alert to her name being called. An LPN later confirmed that Resident #30 was a fall risk and had recently returned from the hospital after a UTI. The call light was found between the bed and the wall and was not reachable by the resident. A CNA stated that the call light should have been within reach and said it had been dislodged during care that morning and was not placed back in reach. Record review showed the resident was admitted with diagnoses including COPD, and the MDS indicated a BIMS score of 09, reflecting moderately impaired cognition.
Inaccurate MDS Bladder Assessment
Penalty
Summary
The facility failed to ensure the accuracy of resident assessments by incorrectly completing Section H (bowel and bladder) of the MDS for one resident. An observation found the resident lying in bed with a urinary catheter drainage bag attached to the lower portion of the bed frame, and record review showed the resident’s Quarterly MDS with an ARD of 12/19/25 did not indicate an indwelling catheter in item H0100. The resident’s December TAR included an order dated 7/7/25 to change the catheter and catheter bag monthly and as needed. The MDS Nurse confirmed the December 2025 MDS was in error and did not capture the resident’s indwelling catheter. The resident was admitted on 7/2/25 with diagnoses including diverticulosis of the intestine without perforation and a stage 3 pressure ulcer of the sacral region, and the resident’s later MDS showed a BIMS score of 15, indicating cognitive intactness.
IDT Care Plan Review Not Fully Documented
Penalty
Summary
The facility failed to ensure the interdisciplinary team (IDT) reviewed and revised Resident #18’s comprehensive care plan to reflect changes in the resident’s condition. Facility policy titled Care Plan Process stated that the comprehensive care plan is an interdisciplinary communication tool and must be reviewed and revised on an ongoing basis by a team of health professionals, including the attending physician, RN, nurse aide, food and nutrition services staff, the resident, the resident representative to the extent practicable, and other disciplines as appropriate. The report stated that the care plan review forms dated 3/13/2026, 12/16/2025, and 9/26/2025 showed only the Social Services Director signed the forms for the meetings, while the resident representative attended by telephone. Progress notes dated 9/25/2025 documented contact with the responsible party for a scheduled care plan meeting with no response. During interview, the MDS Coordinator, MDS Nurse, and Administrator stated the MDS team develops the assessment calendar, the Social Worker schedules care plan meetings, and the IDT includes MDS, therapy, Social Services, Activities, and Dietary staff. The Administrator stated Resident #18 was cognitively and physically able to participate in care plan meetings and be involved in care. Record review showed Resident #18 was admitted with End Stage Renal Disease, and the MDS with ARD 3/4/26 documented a BIMS score of 15, indicating the resident was cognitively intact.
Failure to Apply Ordered Wrist Splint
Penalty
Summary
The facility failed to provide services to maintain or improve range of motion for one resident by not ensuring a physician-ordered right wrist splint was applied daily as ordered. Resident #17 had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side and contracture of the right hand. The facility policy for Range of Motion stated its purpose was to improve or maintain joint mobility and muscle strength and to prevent contractures. Observations showed the resident lying in bed, non-verbal with eyes open, with his right hand contracted and no wrist splint in place. A hand splint was observed on the seat of the wheelchair in the room, and RN #1 stated she did not know why it was there and had never put a hand splint on him. RN #1 also stated she was not aware of an order for the splint and that the March 2026 TAR did not indicate it needed to be worn daily. The DON confirmed the order for the hand splint to be placed for four hours a day and stated it was not entered correctly on the TAR, so nurses did not know to do it. The Director of Rehab stated the splint had been ordered in the summer of 2025 and that nurses had been educated to apply it, but it was not being done as ordered.
Improper Foley Catheter Drainage Bag Positioning
Penalty
Summary
The facility failed to ensure proper positioning and management of an indwelling urinary catheter drainage system for one resident reviewed for urinary catheter care. The facility policy titled Perineal Care, revised 1/24, stated under Resident with Catheter to ensure tubing is not positioned above the level of the bladder. Resident #11 had an order dated 7/3/25 for Foley catheter care every shift and as needed, and the resident was admitted on 7/2/25 with diagnoses including diverticulosis of the intestine without perforation and a stage 3 pressure ulcer of the sacral region. The Minimum Data Set with an ARD of 3/13/26 showed a BIMS score of 15, indicating the resident was cognitively intact. An observation on 3/17/26 at 11:29 AM showed Resident #11 lying in bed with a urinary catheter drainage bag attached to the lower portion of the bed frame. During catheter care on 3/18/26 at 11:00 AM, the CNA and RN removed the drainage bag from the lower bed frame and placed it in the bed with the resident, which caused urinary backflow from the drainage bag into the tubing. The RN confirmed at 11:12 AM that the drainage bag was not positioned appropriately to allow proper drainage during catheter care and stated the urine could reflux and increase the risk for a urinary tract infection.
Improper Storage and Dating of Insulin on Medication Cart
Penalty
Summary
The facility failed to ensure that insulins were stored in accordance with the manufacturer's guidelines on the 300 hall medication cart. During observation with an LPN, several insulins in use were found either without an open date or beyond the 28-day room temperature storage limit: an open vial of Novolog for Resident #2 was undated, an open vial of Humalog for Resident #3 was dated 12/23/25, an open vial of Insulin Aspart for Resident #17 was undated, and a Humalog KwikPen for Resident #51 was undated. Review of the manufacturer's instructions for Humalog and Novolog (Insulin Aspart) showed that once opened, these insulins may be stored at room temperature for up to 28 days before being discarded. The facility policy titled Medication Storage stated that supplies and equipment must be maintained according to the manufacturer's specifications. During interview, the LPN stated that if insulin did not have an open date, there would be no way to determine whether it was still safe to administer, and that out-of-date insulin would not be as effective and could result in residents' blood glucose not being controlled. The DON stated that insulins on medication carts should be checked to ensure they are labeled with an open date and are not beyond the 28-day use period.
Infection Control Failures With Glucometer Disinfection and ESBL Precautions
Penalty
Summary
The facility failed to properly disinfect a glucometer after use during one observed medication administration pass. An LPN was observed cleaning the glucometer with a Micro Kill Two wipe by wiping the front and back of the device and then placing it immediately back into the storage pouch. The facility policy required critical and invasive resident care devices, including glucometers, to be cleaned and disinfected according to manufacturer recommendations, and the manufacturer instructions stated that the surface must remain visibly wet for a 2-minute contact time. During interview, the LPN stated she cleaned glucometers the way she was taught in nursing school and was not aware that the device had to remain wet for 2 minutes. The DON stated nurses were supposed to clean the glucometers after each use and wrap them with the wipe for at least two minutes before storing them. The facility also failed to ensure contact precautions were in place for Resident #30. Record review showed the resident had a urine culture obtained that resulted in ESBL, and the DON later confirmed the lab results and stated the resident should have been on contact precautions, but precautions were not initiated. An LPN confirmed the resident had the ESBL diagnosis and was not on contact precautions. The DON also stated she had been performing the infection prevention role for about 6 to 8 months after the nurse left and said she did not know what would happen if she were out, adding that she was the only one with IP certification and had voiced her concerns. The resident’s face sheet showed admission with diagnoses including COPD.
Failure to Develop Comprehensive Care Plans for Pressure Ulcers
Penalty
Summary
The facility failed to develop a comprehensive care plan for two residents with pressure ulcers. Resident #28 acquired an unstageable pressure ulcer on the right fourth ring finger due to pressure from fingers contracted in a fist. Despite the presence of a functional limitation in the range of motion in the upper extremity, the care plan did not include pressure reduction interventions to mitigate the risk of pressure ulcers. Interviews with the Wound Treatment Nurse and MDS Nurses confirmed the absence of a care plan addressing the risk of skin breakdown related to the resident's hand contracture. Similarly, Resident #209 developed a new pressure wound on the right Achilles area, but no care plan was established for wound care or pressure ulcer management. The Wound Treatment Nurse and the facility Administrator confirmed the lack of a care plan for Resident #209's wound care. The MDS Nurse reiterated the importance of care plan development to ensure that staff are informed of the necessary level of care for the resident's condition.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to provide adequate treatment and preventive measures for pressure ulcers for two residents. Resident #28 developed an unstageable pressure ulcer on the right fourth ring finger due to a contracture in the hand. The facility's records showed no orders for pressure relief devices prior to the ulcer's development. Interviews with staff confirmed that a palm shield was only applied after the ulcer appeared, and no preventive measures were in place beforehand. The resident had a functional limitation in the upper extremity, which contributed to the development of the ulcer. Resident #209 developed a pressure wound on the Achilles area due to an immobilizer used for an unrepaired femur fracture. The resident reported a new sore under the brace, and the facility did not provide foam as recommended by the orthopedic doctor. The wound treatment nurse was notified of the wound but did not stage it or add the treatment order to the Treatment Administration Record until several days later. The immobilizer was not monitored daily for skin breakdown, and there was no physician order for its use. Interviews with the Director of Nursing and other staff confirmed that the skin under the immobilizer was not assessed daily, and the physician's recommendations were not followed. The wound treatment nurse did not implement the recommended orders, and the wound was deemed avoidable with proper monitoring. The facility admitted Resident #209 with a diagnosis of a displaced fracture, and the resident was cognitively intact at the time of the deficiency.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to submit accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) for the third quarter of fiscal year 2024. This deficiency was identified through staff interviews and record reviews. The facility did not have a policy related to Payroll Based Journal (PBJ) submission, as revealed in a letter signed by the Administrator. The facility's PBJ Staffing Data Report for the specified quarter indicated excessively low weekend staffing. During an interview, the Administrator acknowledged the inaccuracy in the PBJ staffing data submission, attributing it to the corporate office's responsibility for compiling the data. The Administrator also noted that administrative staff were sometimes reassigned to provide direct resident care during staff call-ins, but there was no current method to report this as direct care, contributing to the reporting error.
Resident Privacy Violation
Penalty
Summary
The facility failed to uphold the dignity and privacy of a resident, identified as Resident #17, who was observed uncovered and visible from the hallway. The resident was lying in bed with an adult incontinence brief on, their stomach exposed, and a Percutaneous Endoscopic Gastrostomy (PEG) tube visible. This situation was observed on two separate occasions, with the resident's door open and the privacy curtain pulled back, allowing visibility from the hallway. Licensed Practical Nurse (LPN) #1 confirmed the resident's exposure and acknowledged that the privacy curtain should have been pulled to prevent visibility from the hallway. The Director of Nursing (DON) also confirmed that the situation was a dignity concern. Resident #17 had been admitted to the facility with a diagnosis of Cerebral Infarction, and the incident occurred despite the facility's policy on dignity and respect, which emphasizes maintaining bodily privacy for residents.
Failure to Honor Resident's Right to Make Healthcare Decisions
Penalty
Summary
The facility failed to honor a resident's right to make healthcare decisions regarding cardiopulmonary resuscitation (CPR) for one of the sampled residents. The facility's policy on Advance Directives emphasizes the right of residents to make decisions about their medical treatment, including the acceptance or refusal of care. However, the record review revealed that the Advanced Directive Consent for the resident was signed by a family member, not the resident herself, despite her cognitive ability to make her own healthcare decisions. The resident confirmed in an interview that she was not consulted about her advanced directives or code status and expressed her desire to make her own healthcare decisions. Interviews with facility staff, including the Admission Coordinator and the Administrator, confirmed that the resident was cognitively capable and should have been allowed to sign her consent related to code status upon admission. The Admission Coordinator admitted to allowing a family member to sign the consent, assuming the family member was the Resident Representative, without consulting the resident. The Minimum Data Set (MDS) assessment indicated that the resident was moderately cognitively impaired but still capable of making her own decisions, highlighting the facility's failure to adhere to its policy and the resident's rights.
Deficiency in Catheter Care and Infection Control
Penalty
Summary
The facility failed to provide appropriate catheter care for a resident, leading to a deficiency in infection control practices. During an observation, a CNA was seen cleaning the urinary catheter of a resident with a soapy washcloth, then using the same washcloth to rinse the catheter tubing and urinary meatus without changing gloves. This action was identified as cross-contamination, which could potentially lead to infections. The CNA admitted to not realizing the mistake and acknowledged the risk of cross-contamination. The resident involved was admitted with a diagnosis of neuromuscular dysfunction of the bladder and had an indwelling urinary catheter. The resident was cognitively intact, as indicated by a BIMS score of 15. The facility's policy on perineal care required the use of a clean washcloth for rinsing after cleansing to prevent bacterial cross-contamination. The Infection Control/Treatment Nurse confirmed that the CNA's actions were against the facility's policy and could lead to urinary tract infections.
Failure to Reconcile Controlled Medications
Penalty
Summary
The facility failed to maintain a system of medication records that allows for accurate reconciliation and accounting of controlled medications, specifically in one of the three narcotic storage areas reviewed. The facility's policy requires that controlled substances be accounted for at the beginning of each shift by both the outgoing and incoming nurses. However, it was observed that four vials of Lorazepam, part of the Emergency Drug Kit (EDK), were stored in the medication room refrigerator and were not being counted every shift as required. Licensed Practical Nurse (LPN) #1 confirmed that the Lorazepam was not included in the shift counts with other narcotics and was unaware of how long the vials had been in the refrigerator. Interviews with the Pharmacy Consultant and LPN #2 further revealed that the Lorazepam was not reconciled every shift and was not listed in the narcotic count book. The Pharmacy Consultant confirmed that the Lorazepam had been delivered months earlier and was never added to the medication cart-controlled record books for reconciliation. The Director of Nursing (DON) acknowledged that the EDK Lorazepam should have been included in the narcotic count book to ensure it was counted each shift. This oversight raises concerns about potential narcotic diversion and the facility's compliance with its own policies regarding controlled substances.
Medications Left at Bedside for Resident
Penalty
Summary
The facility failed to ensure a resident's environment was free from accident hazards by allowing medications to be left at the bedside. During an observation and interview, it was found that a resident had a six-ounce bottle of sore throat spray and a one-ounce bottle of lubricating eye drops on her bedside table. The resident, who was moderately cognitively impaired, revealed that she used the eye drops multiple times a day and the sore throat spray as needed, without a physician's order. The resident also mentioned that the staff was aware of the medications being at her bedside since her admission. An interview with an LPN confirmed the presence of medications at the resident's bedside and highlighted the lack of a physician's order, raising concerns about potential overuse or misuse by the resident or other confused residents. The facility's administrator acknowledged that residents were not supposed to have medications at their bedside, as it posed a risk of overdose or adverse reactions. The facility's policy on medication storage emphasized the need for secure storage of medications, which was not adhered to in this case.
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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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