Magnolia Senior Care, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Jackson, Mississippi.
- Location
- 3701 Peter Quinn Drive, Jackson, Mississippi 39213
- CMS Provider Number
- 255275
- Inspections on file
- 19
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Magnolia Senior Care, Llc during CMS and state inspections, most recent first.
Staff did not follow care plan interventions for three residents. One resident with edema was observed without ordered compression hose, a CNA provided peri-care to a resident on EBP without a gown, and suction equipment for a resident who self-suctions was observed dirty and outdated while family was performing the cleaning and tubing care instead of nursing staff. The DON confirmed the care plan and orders were not being followed as documented.
A resident with edema and a history of venous thrombosis was observed without ordered compression hose, and an LPN confirmed the hose were not on even though they were to be applied daily. Another resident with Myasthenia Gravis and dysphagia had suction equipment at the bedside that was discolored and dated, while family members were performing the suction care despite the DON stating this was the nurse’s responsibility; the DON also said no assessment had been completed to confirm the resident could suction independently.
The facility failed to submit complete and accurate PBJ staffing data to CMS when contract nursing hours were omitted from the PBJ report. The LNHA stated he compiled and submitted PBJ data using corporate employee files and separately received vendor data for contract staff, but later confirmed that contract nursing hours were not included for several dates. The PBJ staffing report also identified excessively low weekend staffing, while the DON stated staffing was based on resident acuity and the facility assessment and that the schedule supported a census of 55 residents.
A CNA failed to follow EBP and hand hygiene requirements during high-contact care, including providing peri care without a gown for a resident on EBP and not sanitizing or washing hands before care for another resident. A resident who self-suctions was observed using exposed suction equipment that was not protected in a bag, while the DON stated nursing was responsible for changing and cleaning the tubing and device. The DON and IP nurse confirmed the residents were placed at increased risk for infection.
A resident’s room had a posted sign instructing staff to apply compression hose daily and remove them at bedtime. The resident, who was cognitively intact and had edema and a history of venous thrombosis and embolism, stated her legs were swollen and she did not yet have the hose on. An LPN confirmed the sign was meant to remind CNAs, while the DON stated the signage was a dignity issue and should not have been on the wall.
Two residents in a facility were not provided with the required two-person manual assistance during transfers, as specified in their care plans. One resident suffered a fall and head injury when a CNA attempted a lift transfer alone, despite the care plan's instructions. Another resident was transferred by a single CNA who disregarded the two-person assist requirement, believing his physical capability sufficed. These actions demonstrate a failure to adhere to care plans, risking resident safety.
A resident was injured when a CNA improperly used a lift for transfer, contrary to the care plan requiring a two-person manual assist. The resident suffered a head laceration and was hospitalized. Another resident was transferred by a single CNA, despite needing two-person assistance, due to a misunderstanding of the care plan. Both incidents highlight the facility's failure to follow transfer protocols, placing residents at risk.
A facility failed to update a resident's care plan to include their Dementia diagnosis, despite the resident being prescribed Aricept for the condition. Staff interviews confirmed the care plan should have been updated to guide appropriate care. The resident was cognitively intact, with a BIMS score of 15.
A resident in an LTC facility was unable to make informed meal choices due to the absence of a menu in his room and lack of communication from staff. Interviews revealed confusion among staff about who was responsible for informing residents of meal options, leading to the resident feeling compelled to eat what was provided without being aware of alternatives. The DON acknowledged the facility's failure to ensure residents' rights to choose their meals.
Failure to Follow Care Plan Interventions
Penalty
Summary
The facility failed to implement comprehensive care plans by not following physician orders and care plan interventions for three residents. The facility policy required a comprehensive person-centered care plan with measurable objectives and timeframes to meet residents’ medical, nursing, and psychosocial needs. Surveyors observed that staff did not follow the documented care plan interventions for compression hose use, suction equipment care, and Enhanced Barrier Precautions during direct care. For one resident with chronic recurring bilateral lower-extremity edema and a history of venous thrombosis and localized edema, the care plan directed staff to apply bilateral knee-high compression hose every morning and remove them at bedtime per physician order. During observation, the resident was in bed without the compression hose on and stated her legs were swollen and that her CNA would put them on after lunch. A later interview with an LPN confirmed the hose were not on, and the DON stated the hose were intended to decrease swelling and increase circulation and were expected to be applied in the morning after breakfast. For another resident with a PEG tube and on Enhanced Barrier Precautions, a CNA provided perineal care without wearing a gown, despite the care plan directing staff to observe EBP during high-contact care. For a third resident who self-suctions and had orders for suction care, the suction tubing and yankauer were observed dingy yellow and cloudy with a date of 9/15/25. The resident and her son-in-law stated he handled the suction machine care, while the LPN confirmed the tubing was old and said the family was changing and cleaning it, although the DON stated this was the nurse’s responsibility and that family members were not supposed to change tubing or clean the machine.
Failure to Follow Ordered Care for Compression Hose and Suction Equipment
Penalty
Summary
The facility failed to follow physician orders for two residents by not providing ordered care and treatment. Resident #6, who had diagnoses including a personal history of venous thrombosis and embolism and localized edema, was observed in bed with swollen legs and stated she did not yet have her compression hoses on. The resident said her CNA would put them on after lunch. Later that day, an LPN confirmed the resident did not have compression hose on, and stated they should be put on daily. The resident’s order directed staff to apply bilateral knee-high compression hose every morning and remove them at bedtime for edema. Resident #22, who had diagnoses including Myasthenia Gravis and dysphagia following cerebrovascular disease, was observed with suction equipment at the bedside. The yankauer and tubing were described as dingy yellow and cloudy, and the tubing was dated 9/15/25. The resident stated her son-in-law came every evening and changed and cleaned the suction equipment, while the son-in-law later stated he washed the machine and tubing daily but did not change the tubing. The DON stated it was the nurse’s responsibility to change the yankauer weekly and clean the machine on night shift, and that family members were not supposed to do this. The DON also stated there was no assessment of the resident’s ability to properly perform self-oral suctioning, despite an order allowing the resident to suction herself independently as needed.
Incomplete PBJ Staffing Submission
Penalty
Summary
The facility failed to ensure accurate and complete submission of direct care staffing information through the PBJ system to CMS for one fiscal year quarter. The facility policy required electronic submission of complete and accurate staffing information, including agency and contract staff, based on payroll and other verifiable and auditable data. During interview, the LNHA stated he was responsible for compiling and submitting PBJ data, using employee staffing data received from the corporate office and contract nursing staffing data received separately from vendors and manually entered into the PBJ system. The LNHA later confirmed that the data transmitted from the corporate software system was not accurately submitted to the CMS PBJ system and that contract nursing staffing hours for 10/25/2025, 11/22/2025, 12/06/2025, 12/19/2025, 12/27/2025, and 12/28/2025 were not included in the PBJ submission. Record review confirmed those contract nursing staffing hours were omitted. The PBJ Staffing Data Report for FY Quarter 1 2026 identified concerns related to excessively low weekend staffing. The DON stated she and the Staffing Coordinator were responsible for staffing, that staffing was based on resident acuity and the facility assessment, and that the current schedule supported a census of 55 residents with call outs managed without staffing issues. Record review of staffing schedules and daily staffing sheets revealed no staffing shortages or concerns.
Infection Control Failures During Resident Care
Penalty
Summary
The facility failed to prevent the spread of infection by not using proper PPE, not following Enhanced Barrier Precautions (EBP) during high-contact care, not performing hand hygiene before care, and not protecting and maintaining suction equipment as required. Facility policy stated that staff involved in direct resident contact must perform proper hand hygiene before resident care procedures, and that EBP requires targeted gown and glove use during high-contact resident care activities. For one resident with a PEG tube who was on EBP, a CNA provided peri care without wearing a gown. The CNA later confirmed she did not have a gown on while providing peri care and stated the resident was placed at risk for infection. The DON stated the CNA should have donned a gown before peri care and that peri care is high-contact care. The resident’s record showed diagnoses including hemiplegia and hemiparesis following cerebrovascular disease, a history of TIA and cerebral infarction, and dysphagia, and the MDS indicated the resident was dependent on hygiene. For another resident who self-suctions, the suction canker and tubing were observed to be dingy yellow and cloudy, dated 9/15/25, and left exposed on the bed without a covering or bag. The resident repeatedly used the exposed canker to turn the suction on and off. The DON stated the tubing should be changed weekly by nursing and the suction machine cleaned on night shift, and that family was not supposed to change or clean the equipment. For a third resident, a CNA entered the room, donned gloves, assisted the resident, removed the gloves, returned later, donned gloves again, and provided peri care without performing hand hygiene before either care episode. The CNA acknowledged she did not wash or sanitize her hands before entering to provide care, and the DON confirmed hand hygiene should have been performed before and after care and gloves changed after opening the drawer for peri wipes. The residents involved were documented as cognitively intact and dependent on hygiene where applicable.
Personal Signage Posted in Resident Room
Penalty
Summary
The facility failed to honor a resident’s rights to dignity and self-determination by posting personal signage in the resident’s room. During observation, Resident #6 was found in bed with a sign on the wall that read, “Please put on compression hose daily even when resident is in bed. They are to be removed every night at bedtime.” The resident stated her legs were swollen and that she did not yet have her compression hoses on, adding that the facility had placed the sign on the wall to remind staff, but that they still did not do it. The resident was cognitively intact with a BIMS of 13 and had diagnoses including personal history of venous thrombosis and embolism and localized edema. An LPN confirmed the sign was intended to notify CNAs to apply the compression hose and stated the task also appeared in the Kardex daily. The LPN observed that the resident did not have the hose on and stated they should be on daily. The DON later stated the signage in the room was a dignity issue and should not have been on the wall, noting that CNAs should have placed the compression hose on in the morning and that the reminder already appeared in the task system. The order summary directed bilateral knee-high compression hose every morning and removal at sleep every day and night shift for edema.
Failure to Follow Care Plans for Manual Assistance
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) adhered to the comprehensive care plans for two residents, leading to incidents of improper manual assistance. Resident #1, who was admitted with diagnoses including Hemiplegia and Hemiparesis following a cerebral infarction, required extensive assistance from two people for manual transfers as per her care plan. However, a facility-reported investigation revealed that a CNA attempted to transfer her alone using a lift, resulting in a fall and a head injury. The CNA was aware of the requirement for a two-person manual assist but did not follow the care plan, leading to the resident's injury. Similarly, Resident #2, who was also at risk for falls and required a two-person assist for manual transfers, was transferred by a single CNA. Despite the Kardex instructions specifying the need for two-person assistance, the CNA believed that his physical capability as a male negated the need for additional help. This deviation from the care plan was confirmed by the resident and observed by the State Agency. Both incidents highlight a failure to follow established care plans, putting residents at risk of harm.
Failure to Follow Transfer Protocols Leads to Resident Injury
Penalty
Summary
The facility failed to ensure a resident was free from accident hazards, resulting in harm when a resident was dropped from a lift. The incident occurred when a CNA attempted to transfer the resident from the bed to a wheelchair using a lift, contrary to the resident's care plan, which required a manual two-person assist. The resident suffered a laceration to the head and was taken to the hospital. The facility's policy mandates that two trained persons perform lift transfers, but this was not followed, leading to the resident's injury. The resident had a history of hemiplegia and hemiparesis following a cerebral infarction and was unable to participate in interviews due to cognitive communication deficits. Another resident was also at risk of accident hazards when a CNA transferred the resident alone, despite the care plan requiring a two-person manual assist. The CNA incorrectly believed that assistance was only necessary when two females were involved, and as a male, he could perform the transfer alone. This resident was cognitively intact and confirmed the transfer was done by one person. The facility's failure to adhere to the care plans and policies for safe transfers placed residents at risk of harm.
Failure to Update Care Plan for Resident with Dementia
Penalty
Summary
The facility failed to ensure a comprehensive care plan was developed for a resident with a diagnosis of Dementia. The care plan did not include a focus, goals, or interventions related to the Dementia diagnosis, despite the resident being prescribed Aricept for this condition. This oversight was identified during a review of the resident's comprehensive care plan, which should have been updated to reflect the new diagnosis and treatment plan. Interviews with facility staff, including a Registered Nurse and the Director of Nursing, confirmed that the care plan should have included the Dementia diagnosis to guide staff in providing appropriate care. The resident, who was admitted with a diagnosis of Unspecified Dementia, was cognitively intact as indicated by a BIMS score of 15. The facility's policy requires that care plans be individualized and updated with new diagnoses, but this was not adhered to in this case.
Failure to Respect Resident's Meal Preferences
Penalty
Summary
The facility failed to ensure that dietary staff supported and respected a resident's right to make choices about meal preferences. A resident expressed dissatisfaction with the lack of alternative food options and the absence of a menu in his room, which prevented him from making informed choices about his meals. Interviews with the resident revealed that he was not informed of daily menu choices and felt compelled to eat what was provided without being aware of other options. Interviews with facility staff, including the Dietary Manager, Activities Director, and a CNA, highlighted a lack of clarity and responsibility regarding who should inform residents of their meal options. The Dietary Manager believed it was the CNAs' responsibility, while the Activities Director thought it was the dietary aide's duty. The CNA acknowledged that she would inform residents of their options only if asked. The Director of Nursing admitted that the facility did not have a system to ensure that residents who could not leave their rooms were informed of menu choices, acknowledging that this oversight did not align with resident rights.
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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