Middleton Oaks Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Winona, Mississippi.
- Location
- 627 Middleton Road, Winona, Mississippi 38967
- CMS Provider Number
- 255171
- Inspections on file
- 23
- Latest survey
- March 31, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Middleton Oaks Health And Rehabilitation during CMS and state inspections, most recent first.
A resident with hemiplegia, hemiparesis, and cognitive impairment had a care plan directing staff to apply and remove a right ankle splint at specific times each day and to provide passive stretching to prevent decline in ROM. Observation found the splint not in use and lying on a chair, and the resident was unsure when it was last applied. A PTA reported the resident had developed foot drop and that the splint could no longer be applied without additional therapy, attributing this to the splint not being used daily as ordered. The DON confirmed that staff failed to follow the established care plan for splint application and ROM management.
A resident with hemiplegia and hemiparesis after a cerebral infarction, and severe cognitive impairment (BIMS 5), had physician and therapy orders for right-hand and right-ankle splinting with passive ROM to manage contractures and maintain ROM. Surveyors observed a foot splint lying unused and the resident’s right hand contracted into a fist without a hand roll. The resident could not recall when the foot splint was last applied and reported never having a hand roll. An LPN was unaware of the need for the splint and confirmed no hand roll was in use. Records showed the hand splint order was discontinued at the responsible party’s request due to pain, but OT was not notified and no alternative such as a hand roll was initiated. PT had documented improved ankle ROM and recommended a PODUS boot, while a PTA later reported the resident had developed foot drop related to the ankle splint not being applied as ordered. The DON confirmed that daily ankle splint orders existed and that the hand splint was discontinued without alternative interventions to prevent contracture.
Narcotics belonging to two residents were unaccounted for after discrepancies were found in the controlled drug count sheets, with counts altered and documentation missing. An LPN failed to properly reconcile and document narcotic counts, and a discontinued medication was left on the cart. The DON confirmed the missing medications and incomplete records, and the nurse on duty did not cooperate with the investigation.
A resident admitted with a below-the-knee amputation did not attend a required post-operative orthopedic appointment because the physician's order for the appointment was not entered into the medical record. The admitting nurse failed to document the order, and the DON and ADON did not identify the omission during their review, resulting in the missed appointment.
Multiple residents did not receive care as outlined in their care plans, including personal hygiene (such as nail and facial hair care), wound treatment documentation, staff assistance with meals, and administration of PRN medication for nausea and vomiting. Observations and interviews confirmed that residents' needs were unmet despite clear care plan interventions, and staff acknowledged that required care and documentation were not consistently provided.
Nursing staff did not administer a prescribed PRN antiemetic (Zofran) to a resident with a PEG tube who experienced multiple episodes of vomiting and feeding intolerance, despite physician orders and clear clinical indications. The omission was confirmed by documentation and interviews, and resulted in unnecessary discomfort and interruption of enteral feeding.
Staff did not receive education or training on Enhanced Barrier Precautions (EBP), resulting in multiple instances where required PPE was not used during high-contact care activities such as wound care and medication administration via PEG tube. Interviews with nurses, CNAs, and facility leadership confirmed the absence of EBP training and documentation, with the staff educator and administrator acknowledging the deficiency.
Staff failed to use Enhanced Barrier Precautions during high-contact care activities such as wound care and PEG tube handling, did not follow single-use device protocols for a PEG tube declogger, and improperly stored a biliary drainage collection bag on the floor. Multiple staff members and leadership confirmed a lack of training and policy implementation regarding infection control practices, resulting in increased risk for transmission of infectious organisms among residents requiring complex care.
Staff failed to maintain resident dignity by feeding a resident while standing over them in bed and by not covering urinary and biliary catheter drainage bags for three residents, making the contents visible to others. Staff and policy reviews confirmed these actions did not align with dignity standards, and the affected residents had significant medical conditions requiring such care.
Multiple residents experienced unsafe and unclean living conditions, including a missing air conditioner unit cover, damaged furniture with sharp edges, a dirty personal fan, and a persistent foul odor from a stopped-up toilet. Staff interviews revealed lack of communication and unclear responsibilities for maintenance and cleaning, resulting in unresolved hazards and discomfort for residents with varying cognitive abilities.
Surveyors identified a pattern of deficient ADL care, where three residents were observed with untrimmed, dirty nails and unshaven facial hair. Residents expressed a need for grooming, and staff interviews confirmed that nail and shaving care responsibilities were not consistently followed, especially for diabetic and dependent residents. Nursing and CNA staff acknowledged lapses in providing routine hygiene and grooming, resulting in residents not being maintained according to their needs and preferences.
A resident's IV antibiotic medication was left unattended on a bedside table, visible from the open doorway, while the nurse awaited restarting the resident's peripheral IV. Multiple staff confirmed the medication should not have been left unattended, and the facility lacked a specific policy addressing this issue. The resident was cognitively intact and had multiple chronic diagnoses.
A resident with a history of cerebral infarction and muscle weakness, requiring substantial assistance with eating, was observed during multiple meals without adaptive utensils or a divided plate, and without staff assistance, despite facility policy and care plan requirements. Staff interviews confirmed the resident's needs were known but not met, and there were no physician orders for the necessary adaptive equipment.
A resident with Parkinson's disease and dyskinesia was observed on multiple occasions without access to a call light, as it was found hanging over a wall picture and on the floor behind a dresser. Both an LPN and a CNA confirmed the call light was not within reach, and the facility lacked a specific policy regarding call light accessibility.
A resident returned from the hospital with an indwelling catheter, but staff did not obtain a physician's order for the catheter or catheter care. Observation and record review confirmed the absence of necessary orders, and staff interviews revealed that the admitting nurse did not complete the required assessment or ensure orders were entered. The facility also lacked a specific policy for obtaining physician orders, resulting in the resident not receiving proper catheter care or monitoring.
A resident with a Stage 4 pressure ulcer did not have wound care treatments properly documented on twelve occasions, despite facility policy requiring such documentation. The Wound Care RN admitted to missing documentation due to system entry issues, and the DON confirmed the lack of records for these treatments, which are essential for continuity of care.
Failure to Implement Care Plan for Ankle Splint and ROM Management
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan for contracture management and splinting to prevent decline in range of motion for one resident. The facility’s policy on prevention of decline in range of motion required that, based on the comprehensive assessment, the facility provide interventions, exercises, and/or therapy to maintain or improve ROM. The resident’s care plan, initiated on 8/1/25, identified an ADL self-care performance deficit related to stroke, hemiplegia, and immobility, placing the resident at risk for functional decline. The care plan interventions directed staff to apply a splint to the right ankle after breakfast, provide passive stretch to the right ankle after applying the splint, remove the splint at lunchtime, reapply the splint after supper with passive stretch, and remove the splint at bedtime. On observation, the resident’s ankle splint was not in use and was found lying in a chair in the resident’s room, and the resident was unsure when the splint was last applied. The PTA reported that the resident had developed foot drop and that the ankle splint could no longer be placed without additional therapy, confirming this was related to the splint not being applied daily as ordered. The DON stated that the care plan was used to inform staff how to care for the resident and verified that staff failed to follow the care plan when they did not apply the ankle splint. Record review showed the resident was admitted with hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, and an MDS assessment indicated a BIMS score of 5, reflecting cognitive impairment at the time of the deficiency.
Failure to Implement ROM and Splinting Orders Resulting in Contractures and Foot Drop
Penalty
Summary
The facility failed to provide ordered range of motion (ROM) and splinting interventions to prevent decline in ROM for a resident with hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side. The resident was admitted with these diagnoses and had physician orders and therapy recommendations for contracture management and splinting. An OT evaluation documented decreased ROM in the right upper extremity and recommended a resting hand splint and a restorative splint and brace program, with a subsequent OT evaluation recommending continuation of the contracture management and splinting program. A physician order directed staff to apply a right-hand splint after breakfast, provide passive stretch to the right elbow, wrist, and hand once daily, and remove the splint before dinner. Another physician order required application of a right ankle splint after breakfast and after supper with passive stretching following application. The facility’s own policy stated that residents without limited ROM should not experience a reduction in ROM unless clinically unavoidable. During observation, surveyors noted a foot splint lying unused in the resident’s chair and the resident’s right hand contracted into a fist without a hand roll in place. The resident reported not knowing when the foot splint was last applied and stated she had never had a hand roll. An LPN stated she did not know why the splint was in the room, believed the resident was not required to wear it, and confirmed the resident did not have a hand roll. Record review showed the right-hand splint order was discontinued at the responsible party’s request due to pain, but the OT reported she had not been notified of this discontinuation and stated a hand roll should have been initiated when the splint was stopped; she further stated the resident’s hand was now contracted into a fist. A PT discharge summary documented improved right ankle ROM with therapy and recommended a PODUS boot daily for up to five hours, while a PTA later reported the resident had developed foot drop and that the ankle splint could no longer be applied without additional therapy, confirming this was related to the splint not being applied daily as ordered. The DON verified that there were physician orders for daily ankle splinting and acknowledged that the right-hand splint was discontinued without alternative interventions to prevent contracture. The resident’s MDS showed a BIMS score of 5, indicating severe cognitive impairment.
Narcotics Misappropriation Due to Inadequate Documentation and Security
Penalty
Summary
The facility failed to protect residents from misappropriation of property when narcotics belonging to two residents were unaccounted for. A discrepancy was identified on the Controlled Drug Count Sheet, with numbers scratched out and rewritten, resulting in a two-card difference. The narcotic count dropped from 34 to 31 packages/sheets without documentation of removal, and the Master List Controlled Drug form for a specific period was missing. One resident's discontinued Norco medication remained on the cart, and another resident's active Norco was also unaccounted for. Staff interviews confirmed that narcotics are supposed to be reconciled each shift, but the process was not properly followed, and documentation was incomplete or altered. The Director of Nursing confirmed that the missing narcotics were not accounted for and that the Master List Controlled Drug form could not be located. The nurse on duty during the shift in question refused to assist with the investigation and was subsequently suspended and terminated. The facility's policy required residents to be free from misappropriation of property, but the failure to properly document, reconcile, and secure narcotics led to the loss of controlled substances belonging to two residents. The residents involved had diagnoses of hypertensive disease without heart failure and cerebral infarction, respectively.
Failure to Document Physician-Ordered Post-Operative Appointment
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one of three residents reviewed for post-operative care. Specifically, a physician-ordered post-operative appointment was omitted from the resident's medical record, resulting in the resident missing the scheduled appointment. The facility's policy requires that all physician orders be accurately documented and promptly implemented in accordance with CMS regulations and state requirements. However, review of the resident's "After Visit Summary" upon admission showed an order for a post-operative visit, but this order was not entered into the resident's order summary report, and only a later appointment was documented. Interviews with the Director of Nursing (DON) revealed that the admitting nurse, who was responsible for entering all admission orders, failed to document the post-operative appointment. The DON and Assistant Director of Nursing (ADON) also missed the omission during their review of admission orders in the clinical meeting the following day. As a result, the resident, who was admitted with a diagnosis of acquired absence of the left leg below the knee, did not attend the required post-operative orthopedic appointment due to the missed order entry.
Failure to Implement Comprehensive Care Plans for Hygiene, Wound Care, Meal Assistance, and Symptom Management
Penalty
Summary
The facility failed to implement comprehensive care plans for multiple residents, resulting in unmet needs in personal hygiene, wound care, meal assistance, and treatment for nausea and vomiting. Several residents were observed with untrimmed, dirty fingernails and facial hair, despite care plans specifying regular nail and grooming care. Interviews with residents and staff confirmed that these personal hygiene interventions were not carried out as documented in the care plans. For example, one resident with diabetes and impaired vision had long, jagged fingernails with a brown substance underneath and expressed a desire for a bath, shave, and nail trim. Another resident with hemiplegia had fingernails approximately one inch long, dirty, and unshaven, also expressing a wish for grooming, which staff confirmed had not been provided according to the care plan. In the area of wound care, a resident with a pressure ulcer had a care plan intervention for daily wound treatments and monitoring. However, documentation revealed that wound treatments were not recorded for 12 days in one month. The wound care RN stated she performed the treatments but failed to document them, and the DON confirmed that documentation is a required part of the care plan process. This lack of documentation meant there was no verification that the care plan was followed as required. For meal assistance and medication administration, the facility did not follow care plans for residents requiring staff support. One resident who required staff assistance with eating was repeatedly observed eating meals unassisted, contrary to the care plan and staff interviews. Another resident with a history of GERD and a physician's order for as-needed Zofran for nausea and vomiting experienced multiple episodes of vomiting and gagging, but the ordered medication was not administered on those occasions. The DON and MDS Coordinator confirmed that the care plans for meal assistance and medication administration were not followed, resulting in unmet resident needs.
Failure to Administer PRN Medication for Vomiting in PEG Tube Resident
Penalty
Summary
Nursing staff failed to administer Zofran 4 mg as needed for vomiting and gagging to a resident with a PEG tube, despite active physician orders and documented clinical indications. On multiple occasions, including when the resident experienced vomiting and feeding intolerance, the as-needed medication was not given, as confirmed by both the Electronic Medication Administration Record (EMAR) and progress notes. This resulted in the resident experiencing repeated episodes of vomiting and discomfort, and required cessation of tube feeding. The resident involved had a history of dysphagia following cerebral infarction, gastrostomy status, gastro-esophageal reflux disease, and acquired absence of other specified parts of the digestive tract. The resident was severely cognitively impaired and unable to communicate needs effectively. Facility policy required medications to be administered as prescribed and in a timely manner, but staff did not follow these protocols, as confirmed by interviews with the Regional Director of Clinical Services and the Director of Nursing.
Failure to Educate Staff on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that nurses and nurse aides received adequate education and training regarding Enhanced Barrier Precautions (EBP), as required by facility policy. Observations revealed that during four high-contact resident care activities, staff did not utilize the required personal protective equipment (PPE), specifically gowns and gloves, as outlined in the EBP policy. These activities included medication administration via PEG tube and wound care for multiple residents. Staff members involved in these activities, including LPNs, RNs, and CNAs, were observed not using EBP during care. Interviews with various staff members, including the wound care nurse, CNAs, the infection control nurse, the staff educator, and the administrator, confirmed that there had been no education or training on EBP provided to staff. The staff educator stated that EBP was not included in the competencies for staff or new hires, and there was no documentation of EBP education prior to her hire date. The administrator acknowledged that a breakdown in EBP practice occurred due to significant staff turnover and confirmed the lack of staff education and documentation regarding EBP.
Failure to Implement Effective Infection Prevention and Control Practices
Penalty
Summary
The facility failed to implement and maintain an effective Infection Prevention and Control Program (IPCP) for several residents, as evidenced by staff not using Enhanced Barrier Precautions (EBP) during high-contact care activities such as wound care and percutaneous endoscopic gastrostomy (PEG) tube handling. Observations revealed that wound care nurses and certified nursing assistants did not don gowns or follow EBP protocols while providing wound care to multiple residents with pressure ulcers and diabetic wounds. Staff interviews confirmed a lack of knowledge and training regarding EBP, and the facility's leadership acknowledged that EBP had not been practiced or taught due to recent staff turnover. Additionally, improper handling of medical devices was observed. An LPN reused a single-use PEG tube declogger for a resident, contrary to manufacturer instructions, and stored the device in an undated, opened package. The same LPN also administered medications via PEG tube without using a gown as required by EBP. Staff interviews confirmed that they had not received training on EBP or the correct use of single-use devices, and facility leadership verified that alternative methods should have been used for tube declogging. Further, the facility failed to ensure sanitary storage of a biliary drainage collection bag for a resident with a biliary drain. The drainage bag was observed lying on the floor, and both nursing staff and leadership confirmed this was an infection control issue. Review of facility policies revealed no guidance on the storage of biliary tube bags, and staff acknowledged the risk of infection associated with improper storage. These deficiencies were identified through direct observation, staff interviews, and record reviews.
Failure to Maintain Resident Dignity During Feeding and Catheter Care
Penalty
Summary
The facility failed to honor residents' rights to dignity and respect, as evidenced by improper feeding practices and the lack of privacy covers for urinary and biliary catheter drainage devices for three residents. One resident was observed being fed by a CNA who stood over him while he was in bed, rather than sitting at bedside, which was confirmed by the CNA and the Nursing Educator as not being in line with maintaining resident dignity. The facility did not have a policy related to providing dignity during meal assistance. Two other residents were observed with urinary catheter and biliary drainage bags that were not covered with privacy covers, making the contents visible from the doorway or hallway. Staff interviews, including with an LPN and the ADON, confirmed that the absence of privacy covers was a dignity issue. Facility policy required urinary catheter bags to be covered, but there was no specific policy for biliary drainage tubes. The affected residents had medical conditions such as sequelae of cerebral infarction, malignant neoplasm of the pancreas, and hemiplegia following cerebral infarction.
Failure to Maintain Safe and Homelike Environment for Multiple Residents
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for several residents, as evidenced by multiple observations and interviews. In one instance, a resident's air conditioner/heating unit cover was found on the floor for at least two consecutive days, with the resident stating that staff were aware but had not resolved the issue. The maintenance supervisor was not informed of the problem, and there was no documentation in the maintenance log. Another resident's dresser had an 18-inch section of jagged, sharp trim protruding, which staff acknowledged could cause injury, but neither the maintenance supervisor nor the assistant director of nursing were aware of the hazard, and it was not documented for repair. Additionally, a resident's personal fan was observed to have a significant buildup of lint and dust, which the resident had previously requested to be cleaned. There was confusion among staff regarding responsibility for cleaning such items, with housekeeping, maintenance, and CNAs each providing different answers. The fan remained uncleaned, and the resident refrained from using it due to its condition. In another case, a resident's room had a persistent foul odor due to a toilet that had been stopped up for about a month. Staff and the maintenance supervisor confirmed the ongoing issue, with repeated but ineffective attempts to address it, and the problem was well known among staff but unresolved. The residents involved had varying degrees of cognitive function, with some being cognitively intact and others having severe impairment or dementia. The deficiencies were observed through direct inspection, staff and resident interviews, and review of facility records and policies. The issues identified were not isolated incidents, as similar deficiencies had been cited in the previous annual recertification survey, indicating a pattern of failure to maintain the physical environment according to facility policy and regulatory requirements.
Failure to Provide Adequate ADL Care and Personal Hygiene
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care to maintain personal hygiene for three residents, as evidenced by observations, interviews, and record reviews. One resident, who was cognitively intact and diabetic, was observed on two occasions with long, uneven fingernails containing a brown substance underneath, visible facial hair, and reported needing a bath and grooming. The LPN confirmed that nail care for diabetic residents was a nursing responsibility and acknowledged the resident's unkempt condition and odor. Another resident, with moderate cognitive impairment and a history of hemiplegia, was observed with long fingernails containing a dark brown substance and significant facial hair growth. The resident expressed a desire for grooming, stating it had been too long since his last shave and nail trim. The CNA assigned to this resident admitted she did not ask about shaving or nail care and was unaware of the protocol for diabetic residents. The LPN and DON both confirmed the resident's nails were dirty and too long, and that grooming should have been provided during bath days without requiring the resident to request it. A third resident, who was cognitively intact and required assistance with personal care due to spinal cord injury and other diagnoses, was found with excessively long and jagged toenails. The CNA responsible for this resident acknowledged that toenail care was her responsibility for non-diabetic residents but had not performed it. Both the LPN and DON confirmed the resident's toenails were overdue for trimming and not maintained according to the resident's needs and preferences. These findings demonstrate a pattern of failure to provide necessary ADL care, specifically in grooming and nail hygiene, for multiple residents.
Unattended IV Medication Left in Resident Room
Penalty
Summary
A deficiency was identified when a bag of intravenous (IV) fluids with a vial of medication attached was observed lying unattended on a resident's bedside table. The medication was confirmed by the resident to be her antibiotic, which was awaiting administration after her peripheral IV was to be restarted. The medication was visible from the open doorway, and the resident's room door was open to the hallway, making the medication accessible to others. Multiple staff members, including a registered nurse, the RN supervisor, and the assistant director of nursing, confirmed that the medication should not have been left unattended and acknowledged that this was inappropriate. Record review indicated that the resident involved was cognitively intact, with a Brief Interview for Mental Status (BIMS) score of 15, and had diagnoses including polyneuropathy, COPD, and type 2 diabetes mellitus. The facility did not have a specific policy addressing unattended medication, as confirmed by a statement from the administrator. The scope and severity of the deficiency were increased due to a previous citation for a similar issue on the last annual recertification survey.
Failure to Provide Adaptive Eating Equipment and Assistance
Penalty
Summary
Staff failed to provide a resident with adaptive eating equipment and necessary assistance during three observed meals. The resident, who had a history of cerebral infarction, muscle weakness, and required substantial to maximal assistance with eating, was observed eating independently without adaptive utensils or a divided plate, despite struggling to hold her spoon. The facility's policy required assistive devices to be provided as identified in the individualized care plan, but these were not present during the observations. Interviews with staff confirmed that the resident was supposed to have a divided plate and assistance from a CNA during meals, as indicated on her meal ticket and recommended by the occupational therapist. However, the CNA assigned was unaware of the resident's needs, and there were no physician orders for the adaptive equipment. The resident's Minimum Data Set assessment also documented her need for substantial assistance with eating, but this support was not provided during the observed meals.
Failure to Ensure Call Light Accessibility for Resident with Parkinson's Disease
Penalty
Summary
Staff failed to ensure that a resident's call light was within reach on two of three survey days. Observations showed that the call light was hanging over a picture on the wall, with the end of the call button on the floor behind a bedside dresser, making it inaccessible to the resident. The resident was observed both lying in bed and sitting in a chair during these times, and in both instances, the call light was not accessible. Interviews with an LPN and a CNA confirmed that the call light should have been within the resident's reach and acknowledged that it was not. The LPN stated that she frequently found call lights out of reach and confirmed that the resident would not be able to call for help if needed. The resident's admission record indicated a diagnosis of Parkinson's disease with dyskinesia, which may impact mobility and the ability to access the call light. The facility did not have a specific policy for call lights.
Failure to Obtain Physician Orders and Provide Catheter Care
Penalty
Summary
A deficiency occurred when a resident returned from the hospital with an indwelling urinary catheter, but the facility failed to obtain a physician's order for the catheter or for catheter care. Observation revealed the resident in bed with a catheter drainage bag visible, and record review confirmed there were no active orders related to the catheter. Staff interviews indicated that the admitting nurse did not complete the necessary hospital return assessment or ensure that appropriate orders were entered into the system. The facility's daily stand-up meetings, intended to capture and correct new orders, did not identify or resolve the missing catheter orders for this resident. Further review of the resident's progress notes and admission record confirmed the presence of an indwelling catheter and relevant medical diagnoses, including hemiplegia and hemiparesis following a cerebral infarction. Staff interviews acknowledged that without physician orders, the resident would not receive proper catheter care or monitoring for complications. The facility also lacked a specific policy for obtaining physician orders, as confirmed by the administrator.
Failure to Document Wound Care for Resident with Stage 4 Pressure Ulcer
Penalty
Summary
The facility failed to document the completion of wound treatments for a resident with a Stage 4 pressure ulcer. According to the facility's policy, nurses are required to apply a clean dressing to wounds as ordered and document the procedure in the medical record. A review of the resident's medical orders showed a daily wound care regimen for a sacral pressure ulcer, which was in place for over a month. However, the electronic treatment administration record (ETAR) for March showed that documentation was missing for twelve specific dates when the wound care should have been administered. Interviews with the Wound Care RN revealed that she performed the wound treatments on the days she worked but failed to document them in the ETAR, attributing the oversight to the way entries were displayed in the system. The Director of Nursing confirmed that documentation was not completed for twelve wound treatments and emphasized that accurate documentation is necessary for continuity of care. The resident involved had a history of a sacral pressure ulcer and Type 2 Diabetes Mellitus and was rarely or never understood, according to the most recent assessment.
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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