Ms Care Center Of Morton
Inspection history, citations, penalties and survey trends for this long-term care facility in Morton, Mississippi.
- Location
- 96 Old Highway 80 East, Morton, Mississippi 39117
- CMS Provider Number
- 255250
- Inspections on file
- 17
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 10 (2 serious)
Citation history
Health deficiencies cited at Ms Care Center Of Morton during CMS and state inspections, most recent first.
Failure to honor a resident's right to refuse fingerstick blood glucose checks and use a CGM for monitoring. A resident with Type 2 DM and moderately impaired cognition repeatedly stated that fingersticks hurt and that he did not like them, while his daughter and RR reported staff kept doing fingersticks even after providing the CGM and posting signage. An LPN continued the fingerstick despite the resident's refusal, and the DON confirmed the facility had agreed to use the CGM if supplies were provided.
Leaky Faucet Not Repaired in Resident Room: A resident with COPD and intact cognition had a leaking sink in her room that remained unrepaired after she had previously reported it. The Maintenance Director confirmed the work order was overdue, and the Administrator acknowledged the repair request had not been completed; the resident reported the dripping water interrupted her sleep.
A resident with dementia and moderately impaired cognition was receiving quetiapine for hallucinations and sertraline for depression, but the facility did not attempt or document a GDR for the psychotropic medications. The MDS noted no GDR had been documented as clinically contraindicated, and interviews with the DON, pharmacy consultant, NP, attending physician, and Administrator confirmed the GDR was missed.
Care plans were not revised after repeated falls for two residents with fall risk. One resident had chronic kidney disease and moderately impaired cognition, and another had a history of falling with intact cognition. Although both care plans listed a safety focus and multiple fall events, the intervention dates did not match the falls and did not show updated or newly implemented interventions, which RN and DON confirmed.
A resident with Type 2 DM and moderately impaired cognition had an insulin order tied to blood glucose checks, but staff used both a facility glucometer and a CGM without a physician order for the CGM. MAR review showed multiple missing BG readings, inconsistent code entries, and absent progress notes across several months, while staff interviews confirmed confusion about whether the CGM or glucometer should be used and awareness gaps in documentation practices.
Consultant pharmacist monthly MMRs failed to identify and report medication irregularities for a resident receiving insulin, including missing BG documentation, inconsistent MAR entries, and insulin administration records that did not align with the order. The pharmacist also failed to identify the absence of a GDR for a resident receiving psychotropic meds, and the pharmacy reports did not include resident-specific findings or show which residents were reviewed. The DON confirmed no GDR documentation existed and that she had not received a pharmacist recommendation.
Insulin was administered outside physician-ordered parameters for a resident with Type 2 DM and moderately impaired cognition. MAR review showed multiple doses of NovoLog given when BG readings were below the ordered threshold, and one dose given at a lower-than-ordered amount for a higher BG reading, with no documentation or clarification in the record. An LPN stated she had not paid attention to the MAR codes, and the DON confirmed the doses did not match the order and were medication errors.
Improper food storage and labeling were observed in the dietary department when frozen pizza was left unlabeled and undated, opened meat and egg items were resealed without proper dating, and an open container of imitation bacon bits was stored without labeling. Surveyors also found expired buttermilk, deteriorated celery, lettuce that was opened and dated after its best-by date, and soy sauce stored in dry storage despite instructions to refrigerate after opening.
A male resident with a history of sexually inappropriate behaviors was not placed under supervision or subject to care plan interventions, despite prior incidents. This led to two female residents with severe cognitive impairment being inappropriately touched in the day room on separate occasions. Staff failed to communicate the initial incident, resulting in the resident being left unsupervised and able to reoffend before one-to-one observation was implemented.
A facility failed to update and implement a care plan for a resident with a history of sexually inappropriate behaviors, despite documented incidents and psychiatric evaluation indicating severe cognitive impairment and poor judgment. The resident was left unsupervised after an initial incident and subsequently inappropriately touched two other cognitively impaired residents in the day room. Staff interviews confirmed the care plan was not updated until after these incidents occurred.
A resident with a history of skin conditions had a prescribed face cream left at their bedside by an LPN, contrary to facility policy. The resident used the cream unsupervised, leading to facial irritation. The medication was initially prescribed for Actinic Keratosis but was discontinued early due to the adverse reaction. The facility's policy prohibits leaving medications at the bedside without a physician's order and assessment of the resident's capability for self-administration.
Two residents, a married couple, were not allowed to go outside together due to a past incident where one tried to assist the other to prevent a fall. Despite being cognitively intact and expressing a strong desire to spend time outdoors together, they were consistently denied this opportunity by staff. Interviews revealed a lack of awareness and communication among staff regarding the restriction, highlighting a failure to uphold the facility's policy on resident rights.
A facility failed to ensure a resident without an advance directive received assistance in formulating one. The resident, diagnosed with Dysphagia, Dementia, and Alzheimer's Disease, lacked a Power of Attorney and an Advance Directive. Despite providing a booklet on Advance Directives to the resident's representative, there was no documentation confirming acknowledgment of this information.
A facility failed to accurately complete an MDS discharge assessment for a resident with COPD, Hypertensive Chronic Kidney Disease, and Hypertensive Heart Disease with Heart Failure. The resident was discharged to home, but the MDS was incorrectly coded as a hospital stay. Interviews revealed the error was due to incorrect coding by an MDS nurse.
A resident with chronic heart failure and COPD did not have their oxygen tubing changed weekly as required by their care plan. Observations revealed the tubing was not dated, and staff confirmed the oversight. The care plan and physician's orders specified weekly changes, which were not followed, leading to a deficiency.
A facility failed to follow its standards of practice for respiratory care by not dating or properly storing oxygen tubing for a resident with COPD and heart failure. Observations showed the tubing was not dated or stored in a plastic bag when not in use, contrary to facility policy. Interviews with staff confirmed the expectation to change, date, and store tubing weekly, which was not adhered to in this case.
The facility failed to provide meals that were palatable and at an appetizing temperature for three residents. Complaints included food being cold, bland, and lacking seasoning. Observations confirmed that food temperatures were below desired levels. The dietary staff faced challenges due to inadequate training and the use of an open cart system, which contributed to the cooling of food before reaching residents.
The facility failed to prevent potential infection spread by improperly handling linens and not adhering to PPE protocols. A CNA placed dirty linens on the floor, and an LPN did not wear a gown while administering a PEG tube feeding, despite EBP requirements. These actions were confirmed by facility staff, including the DON and Infection Preventionist.
Failure to Honor Resident Preference for CGM Use Instead of Fingersticks
Penalty
Summary
The facility failed to honor a resident's right to refuse fingerstick blood glucose checks and to use a Continuous Glucose Monitor (CGM) for blood glucose monitoring. Resident #16 was admitted with Type 2 Diabetes Mellitus and had a BIMS score of 8, indicating moderately impaired cognition. The resident had a physician's order for sliding scale insulin twice daily and blood glucose checks before lunch and supper. The resident reported that he did not like having his fingers poked and said it hurt, and his daughter and resident representative reported that staff continued to perform fingersticks even after they provided the CGM device and supplies and placed signage in the room directing staff to use the CGM reader instead of fingersticks. During observation, the CGM sensor was seen on the resident's left upper arm and the reader was on the overbed table, but an LPN stated she was not aware the resident had a CGM and had been using the facility glucometer. When the resident again stated he did not like fingersticks, the LPN continued to perform the fingerstick blood glucose check. Another LPN reported awareness of the CGM and the signage but was unsure whether there was a physician order for the device. The DON confirmed the facility had agreed to use the CGM if supplies were provided, but she was not aware of the signage and had not followed up with staff or the daughter regarding its use. The DON and Administrator stated staff are expected to honor and respect resident rights and preferences.
Leaky Faucet Not Repaired in Resident Room
Penalty
Summary
The facility failed to ensure a resident's right to a safe, clean, comfortable, and homelike environment when a leaky faucet in the resident's room was not repaired. The facility's maintenance policy stated that plumbing fixtures were to be maintained in good working order and that maintenance personnel were responsible for establishing priorities for repair service. The resident involved was admitted with COPD and had a BIMS score of 15, indicating cognitive intactness. During observation, the sink in the resident's room was found leaking water, and the resident reported that she had previously reported the problem but it had not been repaired. She stated she had been told the sink would be fixed but could not recall when the request was made. The Maintenance Director confirmed the work order had been submitted and acknowledged the repair was overdue, explaining that the repair required addressing the valves before replacing the faucet. The resident later reported that the dripping water interrupted her sleep, and the Administrator acknowledged that the repair request had not been completed and that only a temporary repair had been attempted previously.
Failure to Document GDR for Psychotropic Medications
Penalty
Summary
The facility failed to ensure a resident was free from unnecessary chemical restraints related to psychotropic medications when it did not attempt or document a gradual dose reduction (GDR) for a resident receiving antipsychotic and antidepressant medications. Resident #79 was admitted with a diagnosis including dementia and had physician orders for quetiapine 25 mg at bedtime for hallucinations and sertraline 200 mg daily for depression. The resident’s quarterly MDS showed a BIMS score of 12, indicating moderately impaired cognition, and documented that no GDR had been documented by a physician as clinically contraindicated. Record review showed the medications were administered as ordered, but there was no documentation of any GDR in the medical record. The facility policy stated residents on psychotropic medications should receive GDRs unless clinically contraindicated, with attempts in two separate quarters during the first year after initiation. During interviews, the DON, pharmacy consultant, NP, attending physician, and Administrator all acknowledged that no GDR had been completed for the resident, and the DON stated she had assumed medication reviews without changes were considered a GDR.
Care Plans Not Revised After Repeated Falls
Penalty
Summary
The facility failed to ensure the comprehensive care plan was revised when residents experienced multiple falls and failed to ensure care plan interventions were dated to reflect new or revised individualized interventions for two residents reviewed for care plans. The facility policy, Develop/Implement Comprehensive Care Plan, stated that a comprehensive person-centered care plan would be developed and implemented for each resident. Record review showed one resident was admitted with chronic kidney disease and had a BIMS score of 11, indicating moderately impaired cognition, while another resident was initially admitted in 2022, readmitted in 12/2025, had a history of falling, and had a BIMS score of 15, indicating intact cognition. For both residents, the care plan included a safety focus identifying them as high risk for falls and listed multiple fall dates, but the intervention dates did not align with the dates of the falls. The record also showed repeated falls for one resident on 12/5/25, 12/7/25, and 1/21/26, and for the other resident on 10/24/25, 10/29/25, 11/22/25, 1/22/26, and 2/7/26. RN #1 and the DON both confirmed that care plans should be updated after a fall and that interventions should be dated to reflect when they were initiated, but after review they confirmed the care plans did not include updated or newly implemented interventions following the repeated falls.
Inconsistent Blood Glucose Monitoring and Missing Documentation
Penalty
Summary
The facility failed to ensure services were provided in accordance with professional standards of practice for a resident with Type 2 diabetes mellitus who was admitted on 1/12/26 and had a BIMS score of 8, indicating moderately impaired cognition. The resident had an order for NovoLog insulin to be given before lunch and supper based on blood glucose results, but there was no physician order identified for the use of a Continuous Glucose Monitor (CGM), even though a CGM sensor was observed on the resident’s left upper arm and a reader was present in the room. The resident reported not liking fingersticks, and a sign in the room instructed staff to use the Freestyle Libre 3 reader to check blood sugar. Record review showed inconsistent and incomplete blood glucose monitoring and documentation on the MAR across January, February, and March 2026. Multiple entries reflected no blood glucose reading documented with codes such as 4, 5, 9, or 13, and several of the entries coded as “other/see progress note” or “hold/see progress note” had no corresponding progress note. In other instances, blood glucose values were documented with insulin administered, but no supporting progress note was present. The MAR also showed entries where no blood glucose reading was recorded and code 13 was used to indicate no insulin required. During observations and interviews, one LPN stated she had always obtained blood glucose readings using the facility glucometer and was not aware the resident had a CGM device, while another LPN stated she knew the resident had a CGM and believed staff were using it instead of the facility glucometer. The resident representative reported providing the CGM device and supplies after admission and placing the sign in the room because staff continued to obtain fingerstick readings. The DON reported she was not aware of missing blood glucose documentation or irregularities, and the NP stated she had not been notified of concerns and relied on accurate and complete documentation to make clinical decisions.
Consultant Pharmacist Failed to Identify Medication Irregularities and GDR Absence
Penalty
Summary
The consultant pharmacist failed to complete monthly medication regimen reviews that identified and reported medication-related irregularities for a resident receiving insulin. Resident #16 was admitted with Type 2 diabetes mellitus and had physician orders for NovoLog insulin based on blood glucose readings before lunch and supper. Review of the MARs for January and February 2026 showed multiple instances of missing blood glucose documentation, codes entered without corresponding progress notes, and insulin administration documentation that did not consistently match the recorded information. These irregularities were not identified or reported in the consultant pharmacist’s monthly medication regimen reviews for January or February 2026. The consultant pharmacist also failed to identify and report the absence of a Gradual Dose Reduction for Resident #79, who was admitted with dementia and was receiving psychotropic medications including quetiapine and sertraline. The quarterly MDS documented that the resident received antipsychotic and antidepressant medications and that no GDR had been documented as clinically contraindicated. The medical record contained no documentation of a GDR, and the DON confirmed there was no GDR documentation and that she had not received any recommendation from the consultant pharmacist regarding a GDR. In addition, the facility did not have resident-specific documentation to show which residents were reviewed during the monthly pharmacy reviews for two sampled residents. The January and February 2026 pharmacy reports stated the consultant pharmacist reviewed numerous charts and discussed medications and doses with staff, but they did not identify individual residents reviewed or include resident-specific findings or recommendations for Residents #16 and #79. During interview, the consultant pharmacist stated he conducts monthly reviews and provides reports, but he does not always review MARs and was not aware of the medication errors or irregularities for Resident #16. The DON and Administrator stated they expected the consultant pharmacist to identify and communicate medication irregularities and recommendations during monthly reviews.
Insulin Given Outside Ordered Parameters
Penalty
Summary
The facility failed to prevent significant medication errors when nursing staff administered insulin outside of the physician-ordered parameters for Resident #16, who was admitted with Type 2 Diabetes Mellitus and had a BIMS score of 8 indicating moderately impaired cognition. The physician ordered NovoLog insulin to be given twice daily for hyperglycemia only when blood glucose was greater than 200, with 5 units for readings over 200, 10 units for readings over 300, and to hold the dose if blood glucose was less than 200. Review of the MARs for January, February, and March 2026 showed multiple instances where insulin was administered outside those parameters, including 5 units given when blood glucose readings were 145, 162, 144, 186, and 161, and 10 units given when the reading was 247, as well as 5 units given when the reading was 180. There was no corresponding documentation or clarification in the medical record for these administrations. During interview, an LPN stated she tries to record blood glucose results right away and had not paid attention to the MAR codes or that there were no BG results recorded. The DON later confirmed the documented blood glucose readings and insulin dosages did not align with physician orders and would be considered medication errors, and stated she had not been notified of these errors.
Improper Food Storage and Labeling in Dietary Department
Penalty
Summary
The facility failed to store, prepare, and serve food in accordance with professional standards for food safety. During a kitchen observation, frozen sliced pizza was found in the freezer without being repackaged, labeled, or dated. Two opened bags of Mexican beef taco meat were opened, used, and resealed with rubber bands without labeling or dating, and a bag of shredded lettuce labeled “Best if Used by March 2, 2026” was observed opened and dated March 16, 2026, although the Dietary Manager stated it had been received approximately two weeks earlier. A bag of celery was observed deteriorated and breaking down inside the packaging, and four half gallons of buttermilk were present with expiration dates of March 4 and March 12. Additional food storage concerns were observed in the refrigerator and dry storage areas. Two partially used bags of chopped boiled eggs were resealed with rubber bands, and the Dietary Department confirmed eggs are not shipped in that manner and acknowledged improper storage. One open container of imitation bacon bits was stored in the refrigerator without labeling or dating. One bottle of Kikkoman Reduced Sodium Soy Sauce had been opened and stored on a shelf in the dry goods room despite manufacturer instructions requiring refrigeration after opening. The Dietary Manager stated staff putting away deliveries were responsible for checking expiration dates, and the Administrator stated she expected dietary staff to properly package, store, and date all food items in accordance with facility policy.
Failure to Protect Residents from Sexual Abuse Due to Lack of Supervision and Communication
Penalty
Summary
The facility failed to protect residents from sexual abuse by not implementing immediate supervision or restrictions for a male resident with a known history of sexually inappropriate behaviors. Despite prior incidents of sexual comments and inappropriate conduct toward staff, no care plan interventions or increased supervision were put in place before the resident inappropriately touched two female residents in the day room. The first incident occurred when the male resident touched the breast of a female resident, which was witnessed by a janitor who separated the residents and notified an LPN. After the initial incident, the LPN escorted the male resident to his room but left him unsupervised while reporting the event to the DON. During this time, another CNA, unaware of the incident, assisted the male resident back to the day room, where he subsequently inappropriately touched the breast of a second female resident. Staff interviews confirmed that there was a lack of communication regarding the initial incident, and the male resident was not placed on one-to-one supervision until after the second incident occurred. The male resident involved had a history of cognitive impairment, poor judgment, and previous sexually inappropriate verbal behaviors, as documented in his medical and psychiatric records. Both female residents who were touched also had severe cognitive impairments. The facility's failure to implement protective supervision and communicate the risk to all staff resulted in two residents experiencing non-consensual sexual contact and placed other vulnerable residents at risk.
Removal Plan
- Hold QA meeting to review Abuse Policy and Care plan policies with all disciplines.
- Start 1-1 observation by DON and ADON when an incident is reported. Assign this to the scheduled Certified Nursing Assistant (CNA).
- Conduct in-services on Abuse and Identifying Sexual Abuse and Capacity to Consent by Staff Development Nurse and the Administrator. Train all staff that if staff witnesses abuse, the one who perpetrates or initiates abusive behavior cannot remain in contact with other residents. Take them with you to a supervisor or another employee must remain with them until a decision is made as to what needs to be done. Do not allow staff to work until in-serviced.
- Discipline and educate LPN #1 on 1-1 supervision when there is an abuse allegation.
- Educate CNA #1 on proper undergarment placement for Resident #2.
- Update Care Plans for all Residents involved and review all residents with behaviors and their care plans.
- Conduct body audits on Resident #2 and Resident #3.
- Initiate hourly checks on Resident #2 and Resident #3.
- Send referrals to multiple Geri-psych units and other facilities for Resident #1.
- Assign 1-1 observation of Resident #1 to the scheduled Certified Nursing Assistant (CNA). Use Post Event Hourly Monitoring Form.
- Review Care Plans on Residents with behaviors weekly for 4 weeks, monthly for 3 months, and then quarterly. Social Services Director and Care Plan Nurse will be responsible for reviewing and addressing in QA.
Failure to Develop and Implement Care Plan for Sexually Inappropriate Behaviors
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan addressing sexually inappropriate behaviors for a resident with a known history of such behaviors. Despite documented incidents of sexually inappropriate comments and actions, including a prior event where the resident asked to see a staff member's breasts and a psychiatric evaluation noting sexually impulsive behavior, the care plan was not updated to include individualized interventions, monitoring instructions, or staff guidance. The resident's cognitive status was severely impaired, as indicated by a Brief Interview for Mental Status score of 6 and psychiatric notes describing poor judgment, impaired decision-making, and confusion. On the day of the incident, the resident inappropriately touched the breasts of two female residents in the day room. After the first incident was witnessed by a staff member, the resident was taken to his room but left unsupervised. Another staff member, unaware of the incident, assisted the resident back to the day room, where a second incident occurred. Both female residents involved had severe cognitive impairment and required staff assessment for mental status. The facility had prior knowledge of the resident's sexually inappropriate behaviors but did not implement immediate supervision or restrictions to protect other residents. Interviews with facility staff confirmed that the care plan was not updated until after the incidents occurred, despite escalating behaviors and psychiatric recommendations. The lack of timely and effective care planning and supervision resulted in two residents experiencing non-consensual sexual contact and placed other vulnerable residents at risk.
Removal Plan
- Hold QA meeting to review Abuse Policy and Care plan policies with all disciplines.
- Start 1-1 observation by DON and ADON when an incident is reported, assigned to the scheduled Certified Nursing Assistant (CNA).
- Conduct in-services on Abuse, Identifying Sexual Abuse, and Capacity to Consent by Staff Development Nurse and Administrator. Train all staff that if staff witnesses abuse, the perpetrator or initiator cannot remain in contact with other residents and must be taken to a supervisor or another employee must remain with them until a decision is made. Do not allow staff to work until in-serviced.
- Discipline and educate LPN on 1-1 supervision when there is an abuse allegation.
- Educate CNA on proper undergarment placement for Resident.
- Update Care Plans for all Residents involved and review all residents with behaviors and their care plans.
- Conduct body audits on Residents.
- Initiate hourly checks on Residents.
- Send referrals to multiple Geri-psych units and other facilities for Resident.
- Assign 1-1 observation of Resident to the scheduled Certified Nursing Assistant (CNA) and use Post Event Hourly Monitoring Form.
- Review Care Plans on Residents with behaviors weekly for 4 weeks, monthly for 3 months, and then quarterly. Social Services Director and Care Plan Nurse will be responsible for reviewing and addressing in QA.
Medication Mismanagement at Resident's Bedside
Penalty
Summary
The facility failed to ensure that medications were secured and only accessible to authorized personnel, as evidenced by an incident involving a resident who had a medication left at their bedside. The resident confirmed that a nurse left a prescribed face cream at their bedside, which they used frequently, leading to irritation instead of healing. The resident's daughter was upset about the situation, and the dermatologist was also displeased upon learning that the medication was left unsecured. The resident had been prescribed Fluorouracil 5% topical cream for Actinic Keratosis, to be applied twice daily. However, the order was discontinued early due to the irritation caused by the unsupervised use of the cream. A new order for Triamcinolone Lotion was issued to address the irritation. The LPN involved admitted to leaving the cream at the resident's bedside due to the resident's insistence, and the situation was reported to the previous Director of Nursing. The resident had a history of Type 2 Diabetes Mellitus with Hyperglycemia, Neoplasm of Uncertain Behavior of Skin, Actinic Keratosis, and Rosacea. A mental status assessment indicated moderate impairment. The facility's policy clearly stated that medications should not be left at the bedside unless there is a physician's order and the resident is deemed capable of self-administration, which was not the case here.
Failure to Honor Residents' Right to Self-Determination
Penalty
Summary
The facility failed to honor residents' rights for self-determination by not allowing two residents, who are a married couple, to go outside together. Both residents were cognitively intact and expressed a strong desire to spend time together outdoors. Resident #13, who was independent in activities of daily living, and Resident #14, who used a wheelchair and required staff assistance for transfers, were not permitted to be outside together due to a past incident where Resident #13 attempted to assist Resident #14 to prevent her from falling. Despite their requests to staff, they were consistently denied the opportunity to go outside together, which was important to them given their limited time together due to their respective medical appointments. Interviews with facility staff revealed a lack of awareness and communication regarding the restriction placed on the couple. A CNA in training and an LPN confirmed the restriction, while the Social Services staff and the Administrator were unaware of the issue. The Director of Nursing emphasized the expectation that staff respect residents' rights, but the inconsistency in staff, particularly with the use of agency staff and different personnel on weekends, may have contributed to the oversight. The facility's policy on resident rights emphasizes the importance of self-determination and access to services, which was not upheld in this case.
Failure to Assist Resident in Formulating Advance Directive
Penalty
Summary
The facility failed to ensure that a resident without an advance directive received the necessary information or assistance to formulate one. Resident #7, who was admitted with diagnoses including Dysphagia, Dementia, and Alzheimer's Disease, did not have a Power of Attorney or an Advance Directive. The Admission Agreement Checklist for the resident, dated 10/9/21, indicated the absence of a Power of Attorney and did not acknowledge an Advance Directive. Interviews with the resident's representative and facility staff, including the Administrator and the Director of Nursing, confirmed that there was no documentation of an Advance Directive Acknowledgment Form or Power of Attorney in the resident's records. Although a booklet on Advance Directives was provided to the resident's representative upon admission, there was no documentation to confirm the acknowledgment of this information.
Inaccurate MDS Discharge Assessment
Penalty
Summary
The facility failed to accurately complete a Minimum Data Set (MDS) discharge assessment for one resident, leading to a deficiency. The resident, who had been admitted with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Hypertensive Chronic Kidney Disease, and Hypertensive Heart Disease with Heart Failure, was discharged on August 8, 2024. The discharge MDS was incorrectly coded as a short-term general hospital stay, despite documentation indicating the resident was to be followed up at home by a home health service and left the facility under the care of family. Interviews with the Registered Nurse/MDS Coordinator and an MDS nurse revealed that the error was due to incorrect coding by the MDS nurse, who acknowledged the mistake and stated that the discharge should have been coded as the resident going home.
Failure to Implement Oxygen Tubing Change as per Care Plan
Penalty
Summary
The facility failed to implement a care plan intervention for a resident requiring oxygen therapy. The care plan, which started on March 22, 2023, specified that the resident's oxygen tubing should be changed and the filter washed every week on Friday. However, during an observation on October 15, 2024, it was noted that the oxygen tubing was not dated, indicating it had not been changed as per the care plan. The resident, who has chronic diastolic heart failure and COPD with acute exacerbation, confirmed the need to wear oxygen at all times. Further observations and interviews with facility staff, including a registered nurse and the MDS/Care Plan Coordinator, confirmed the oversight. The RN acknowledged that the tubing was not dated and should have been changed weekly. The MDS/Care Plan Coordinator and the Director of Nursing both emphasized the importance of following the care plan to ensure proper care. The resident's medical records, including a physician's order dated August 27, 2024, reiterated the requirement to change the oxygen tubing weekly, which was not adhered to, leading to the deficiency.
Failure to Follow Respiratory Care Standards
Penalty
Summary
The facility failed to adhere to its standards of practice for respiratory care concerning the management of oxygen tubing for a resident. The resident, who was admitted with diagnoses including Chronic Diastolic Heart Failure and COPD with Acute Exacerbation, was observed receiving oxygen therapy. However, the oxygen tubing was not dated as required by the facility's policy, which mandates weekly changes and dating of the tubing. Observations revealed that the tubing was not stored in a plastic bag when not in use, increasing the risk of contamination. Interviews with nursing staff, including an RN and an LPN, confirmed that the oxygen tubing should be changed weekly, dated, and stored in a plastic bag when not in use. The Director of Nursing also stated that staff are expected to follow these procedures. Despite these expectations, the tubing for the resident was not managed according to the facility's policy, as it was neither dated nor properly stored, indicating a lapse in following the established standards of practice for respiratory care.
Deficiency in Meal Quality and Temperature
Penalty
Summary
The facility failed to ensure that meals were palatable and served at an appetizing temperature for three residents. Resident #63 reported dissatisfaction with the meals, describing them as often cold and lacking flavor. He noted that his meals, including breakfast and lunch, were lukewarm and bland. Resident #85 expressed that the food was either too salty or tasteless, leading her to skip meals due to the lack of seasoning. Resident #90 also complained about the food being bland, cold, and unappetizing, resulting in her family bringing meals from outside. Observations confirmed that food temperatures were below the desired levels, with test trays showing lukewarm temperatures and bland taste. The facility's dietary staff faced challenges in maintaining food quality and temperature. During interviews, it was revealed that the kitchen staff were not adequately trained, with one staff member still learning cooking techniques and another not certified. The use of an open cart system for meal delivery contributed to the cooling of food before reaching residents. Additionally, the loss of recipes due to a previous roof leak led to limited seasoning options, with only salt and pepper being used. The Director of Nursing acknowledged residents' complaints about the food's taste and temperature, and the Administrator was informed of the issues.
Infection Control Deficiencies in Linen Handling and PPE Usage
Penalty
Summary
The facility failed to handle linens properly and did not adhere to the required Personal Protective Equipment (PPE) protocols, leading to potential infection control issues. During an observation, a Certified Nurse Aide (CNA) placed dirty linens and a soiled brief directly on the floor after providing incontinence care to a resident. This action was confirmed by the CNA, a Licensed Practical Nurse (LPN), a Registered Nurse (RN) who is the Infection Preventionist, and the Director of Nursing (DON), all of whom acknowledged that placing dirty linens on the floor could contribute to the spread of infection. The resident involved had been admitted with a diagnosis of Type 2 Diabetes Mellitus. In another instance, a Licensed Practical Nurse (LPN) administered a bolus feeding to a resident with a Percutaneous Endoscopic Gastrostomy (PEG) tube without wearing the required gown, despite signage indicating the need for Enhanced Barrier Precautions (EBP), which include both gloves and a gown. The LPN stated she was instructed that gloves were sufficient, although the facility's policy and the signage on the resident's door required both gloves and a gown. This was confirmed by the RN and the DON, who reiterated the expectation for staff to follow the facility's EBP policies. The resident had been admitted with diagnoses related to a gastrostomy and had a physician's order for EBP due to the feeding tube.
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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