Nmmc Baldwyn Nursing Facility
Inspection history, citations, penalties and survey trends for this long-term care facility in Baldwyn, Mississippi.
- Location
- 739 4th Street South, Baldwyn, Mississippi 38824
- CMS Provider Number
- 255161
- Inspections on file
- 24
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Nmmc Baldwyn Nursing Facility during CMS and state inspections, most recent first.
Insufficient nursing staffing led to missed ADL care and delayed call light response. Two residents were observed unkempt, with long facial hair, dirty nails, disheveled hair, and body odor, and one resident said he had waited two weeks for a bath. A resident also waited for help changing after turning on his call light, while staff were not immediately available and the alarm was silenced. During resident council, residents reported long waits for care and toileting assistance, and the DON acknowledged ongoing staffing shortages, frequent call-ins, and reliance on agency staff.
A resident with heart failure, dementia, mood disorder, anxiety, and depression was started on Seroquel and Buspar without signed informed consent in place. The facility had no policy requiring psychotropic consent forms before initiation, and the MDS Consultant and DON confirmed the consents were not obtained prior to starting the medications. The resident’s BIMS score was 12, indicating moderate cognitive impairment.
Failure to Implement Catheter and ADL Care Plans: The facility did not follow care plans for a resident with an indwelling Foley catheter or for several residents who required ADL assistance with grooming and personal hygiene. Observations showed an unsecured catheter for one resident and multiple residents with untrimmed nails, facial hair, disheveled hair, and poor hygiene. The DON and MDS Coordinator confirmed the care plans were not being implemented as documented.
Failure to Provide Required Grooming and Personal Hygiene Assistance: Several residents were observed with long fingernails, facial hair, disheveled or greasy hair, debris under the nails, and body odor, despite stating they wanted grooming care. The DON and CNA confirmed the residents were not adequately groomed, and staff were unsure when the residents had last received shaving, nail care, or bathing. One resident had functional quadriplegia and spasticity, another had hemiparesis after CVA and DM, and others had cerebral infarction or COPD with total self-care deficit.
Ordered wound care was not completed as prescribed for a resident with a sacral stage 4 pressure ulcer. The resident had a history of functional quadriplegia, muscle spasticity, and ataxia, and the TAR showed missed PM treatments on multiple occasions. RN confirmed the missed care, and the treatment nurse observed the sacral dressing was still dated from the prior day, with the ordered PM dressing change not completed. The DON stated ordered treatments were expected to be completed as prescribed.
A resident with anoxic brain injury, severe cognitive impairment, and total dependence for bed mobility and toileting had repeated falls from bed during care. Staff knew the resident was high risk and that he flailed, thrashed, and could be combative, but a CNA provided care alone and did not check the care plan for the required level of assistance. The DON confirmed there was no fall review to identify the root cause and no interventions were put in place after the resident rolled off the bed.
A resident with an indwelling catheter was observed without a catheter securement device during CNA care. The CNA stated the device was required and must have fallen off, and the DON confirmed the securement device should have been in place for each resident with an indwelling catheter. The resident had moderate cognitive impairment based on a BIMS score of 9.
Failure to Provide Ordered Nutritional Support for a Resident with Significant Weight Loss: A resident with stroke-related dysphagia, vascular dementia, and risk for malnutrition experienced significant weight loss while meal intake was consistently poor. The RD documented the resident’s dislike of the pureed diet and Glucerna, but the supplement order was entered for only a brief period and then stopped, and there was no documentation that the resident actually received the ordered supplement or the recommended nutrients and protein.
A resident with anoxic brain injury and severe cognitive impairment was found partially off the bed with his arms and legs on a protective mat and his face trapped between the mattress and side rail. The bed was against the wall with half side rails in place, but the side rail assessment was not updated after the resident’s fall and significant change in condition. Staff confirmed he was at greater risk for entrapment and suffocation than from falls, and the MDS nurse stated quarterly side rail assessments were not being completed.
Unsecured medications and treatment solutions were found accessible in a resident room, including multiple bottles of Dakin's solution, ethyl alcohol, and hydrogen peroxide left on a table, in a pail, and on a counter. Surveyors also observed an unlocked, unattended med cart; an LPN acknowledged leaving it unsecured, and the DON stated carts should remain locked unless actively in use.
Infection control practices were not followed when a clean utility cart was left uncovered with clean supplies exposed and resident gowns on the bottom shelf touched the floor. Staff also entered a room with EBP and contact isolation signage without wearing gowns, and one aide carried soiled linen against her body without a barrier bag. The IP and DON confirmed that clean linen carts must be covered and that staff caring for residents under EBP or contact precautions are required to wear a gown.
A resident with diabetic venous ulcers and multiple comorbidities did not consistently receive prescribed twice-daily wound care treatments, with documentation showing missed dressing changes on numerous occasions. The wound was observed to worsen significantly, and staff interviews confirmed that wound care was not reliably performed, particularly during night shifts and weekends.
Two residents with stage 4 pressure injuries did not consistently receive wound care treatments as ordered, with missed or undocumented treatments occurring multiple times over a one-month period. Facility leadership confirmed awareness of incomplete treatments but was not fully informed of the extent or reasons for the lapses.
A resident with end stage renal disease, decreased mobility, and severe cognitive deficits did not receive care in accordance with her care plan, as staff failed to change her into bed clothes at night and did not maintain her wound vac on continuous suction as ordered. Multiple observations and staff interviews confirmed that the resident was left in the same clothes from the previous day and that the wound vac was not consistently hooked up to suction, contrary to physician orders and facility policy.
A resident with severe cognitive impairment and total dependence on staff for ADLs was not assisted in changing from day clothes to pajamas before bed, despite facility policy and her expressed preference. Staff interviews and observations confirmed that she frequently slept in her regular clothes, and the issue persisted despite being reported to administration.
A resident with a surgical wound and complex medical history did not consistently receive wound vac therapy as ordered, with multiple instances observed and reported where the wound vac was not hooked up to suction or was left off for extended periods. Staff interviews confirmed the device was supposed to be in use at all times, and the care plan included clear instructions for alternative dressing if the wound vac was not functioning.
Four vials of Ativan requiring refrigeration were left in a locked box inside a malfunctioning medication room refrigerator. Due to miscommunication between two LPNs, the medications were not removed before the refrigerator was taken outside and later disposed of by maintenance. The vials were not recovered, and the loss was discovered the following day when staff realized the refrigerator was missing.
The facility submitted inaccurate staffing data to CMS for one quarter, as the staff member responsible for PBJ entries was new and failed to correctly enter salaried staff hours, leading to a report of excessively low weekend staffing despite adequate shift coverage.
The facility failed to maintain a clean, safe, and homelike environment for residents, with deficiencies observed in several rooms. Issues included missing paint, dead bugs, water stains, broken molding, and unclean air/heat units. The EVS Manager and Assistant Administrator confirmed these problems, acknowledging lapses in cleaning and maintenance processes.
A resident who was cognitively intact and had a history of voting was unable to participate in the 2024 election because staff did not provide the necessary assistance or forms, despite facility policy encouraging support for voting. Social Services did not individually approach residents about voting, and the resident was not given the opportunity to exercise this right.
Two residents with documented serious mental illnesses, as identified by the state PASRR process, were inaccurately coded on their MDS assessments as not having such conditions. This occurred due to a lack of communication between Social Services and the MDS department, resulting in the residents' assessments not reflecting their actual PASRR status.
Insufficient Nursing Staffing Led to Missed ADL Care and Delayed Call Light Response
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet resident needs, including completing ADL care, answering call lights in a timely manner, and addressing repeated resident concerns about delays in care. The facility policy on scheduling nursing staff stated that staffing levels were to support patient and staff safety. During observation, Resident #10 was noted with facial hair on the sides of the face, chin, and neck, fingernails about 1 1/2 inches long with dark substance under them, and disheveled hair with a white flaky substance. The resident stated he needed to be shaved and that his fingernails were very long and had not been done in a long time. Resident #54 was observed with greasy, disheveled hair, facial hair about 1 inch long, fingernails about 1/2 inch long with debris, and a noticeable body odor. The resident stated he was supposed to get a bath the prior night but the two CNAs were too busy to get to him, and later said it had been two weeks. A CNA confirmed that Resident #54 was scheduled for night-shift bathing on Monday, Wednesday, and Friday and that the care included complete hygiene, hair washing, and shaving as needed. The CNA also stated she was not sure when Resident #10 and Resident #54 were last shaved or bathed and reported that residents scheduled for night-shift baths often appeared not to have been cleaned or groomed when day shift arrived. A call light was observed illuminated for Resident #54, who stated he needed to be changed and had been waiting after turning on his light a while earlier. Staff were not immediately present in the area, and the call light alarm at the nurses’ station was silenced. The Unit Coordinator said the CNA had already been paged overhead. During the resident council meeting, residents reported staffing as their primary concern, including being told they would have to wait until the next day for some care and experiencing extended waits for toileting assistance. The DON acknowledged the facility primarily used agency staff, had frequent call-ins that could not always be replaced, and that the facility had ongoing difficulty maintaining adequate staffing to meet resident needs.
Failure to Obtain Informed Consent Before Starting Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent before initiating psychotropic medications for one resident reviewed for unnecessary medications. Resident #2 had active orders dated 2/25/26 for Seroquel 50 mg at bedtime for non-Alzheimer's dementia and Buspar 10 mg three times daily for depression, but the Psychotropic Medication Informed Consent Form was not signed until 3/23/26. The facility had no policy requiring psychotropic consent forms to be obtained prior to initiation of a psychotropic medication. During interviews, the MDS Consultant stated there should have been signed consent for Seroquel and Buspar before initiation, and the DON confirmed that consents were not obtained prior to initiation. Resident #2 was admitted with diagnoses including heart failure, dementia, mood disorder, anxiety, and depression, and the MDS ARD of 3/04/2026 showed a BIMS score of 12, indicating moderate cognitive impairment.
Failure to Implement Catheter and ADL Care Plans
Penalty
Summary
The facility failed to implement care plans for catheter care and activities of daily living for five residents reviewed. The report states that the facility policy required services provided in accordance with each resident’s plan of care, but staff did not follow the documented interventions for residents with an indwelling catheter or for residents needing assistance with grooming and personal hygiene. For Resident #4, the care plan required a Foley catheter related to neurogenic bladder and directed staff to secure the catheter to prevent trauma. During observation, the resident had an indwelling catheter with no securing device in place. CNA #2 stated the device was required and must have fallen off, and the DON confirmed the securing device should have been in place. The MDS Coordinator also acknowledged that residents with indwelling catheters should have a bowel and bladder care plan that included catheter care, and that the facility failed to implement it. For Resident #7, Resident #10, Resident #46, and Resident #54, the care plans included assistance with ADLs such as personal hygiene, grooming, nail care, and shaving. Observations showed Resident #7 had fingernails about one-half inch long and chin hair about one-fourth inch long; Resident #10 had facial hair about one inch long, fingernails about one and one-half inches long with dark substance under the nails, and disheveled hair with white flaky substance; Resident #46 had facial hair under the chin and upper front neck; and Resident #54 had facial hair about one inch long, fingernails about one-half inch long with dark substance underneath, greasy and disheveled hair, and body odor. In each case, the DON and/or MDS Coordinator confirmed the residents were not adequately groomed and that the ADL care plans were not being implemented.
Failure to Provide Required Grooming and Personal Hygiene Assistance
Penalty
Summary
The facility failed to provide ADL assistance for personal hygiene needs for four residents who were observed with untrimmed fingernails, facial hair, and unkempt appearance. Facility policy titled AM/PM Care stated that residents should be shaved per preference and that the purpose of the policy was to promote resident cleanliness. During observations, residents were found with long fingernails, facial hair, and in some cases greasy or disheveled hair, debris under the nails, and body odor. Several of the residents stated they wanted their fingernails trimmed or facial hair removed, and one resident stated it had been a long time since his grooming had been done. One resident with diagnoses including functional quadriplegia, muscle spasticity, and ataxia, and a BIMS score of 13, was observed with fingernails about one-half inch long and dark chin hair on multiple occasions. Another resident with diagnoses including hemiparesis after CVA, PAD, and type 2 diabetes, and a BIMS score of 15, was observed lying in bed unshaven with fingernails up to one and a half inches long, dark substance under the nails, and disheveled hair with white flaky substance throughout. The resident stated he needed to be shaved and have his fingernails cut and cleaned. A third resident with a diagnosis of cerebral infarction and a BIMS score of 15 requested removal of facial hair and was observed with hair under the chin and upper neck. A fourth resident with diagnoses including COPD, total self-care deficit, and traumatic brain injury, and a BIMS score of 14, was observed with about one inch of facial hair, fingernails about one-half inch long with debris, greasy and disheveled hair, and noticeable body odor. CNA and DON interviews confirmed the residents were not adequately groomed, that bathing and grooming were expected to include shaving and hair washing, and that staff were unsure when the residents had last received these services.
Missed ordered wound care for a resident with a sacral pressure ulcer
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met for one resident with a sacral stage 4 pressure ulcer. The resident was admitted with two wounds, including one on the buttock and one on the sacrum, and later reported that one wound had healed while the sacral wound remained present. The resident’s record showed physician orders dated 2/10/2026 for sacral wound treatment two times daily, and the facility policy stated that skin anomalies should be identified and basic wound care should be provided. Review of the TAR for the sacral pressure ulcer showed the ordered wound care was not completed on the PM shift on 3/11/26, 3/14/26, and 3/24/26. During interview, RN #1 confirmed the night shift nurse did not complete the wound treatments on those dates. The treatment nurse observed that the sacral dressing on the morning of 03/26/26 was dated 03/25/26, and the physician’s ordered PM dressing change had not been completed. The DON confirmed it was the facility’s expectation that ordered treatments be completed as prescribed and stated that not completing them could delay wound healing. The resident’s record also showed diagnoses including functional quadriplegia, muscle spasticity, and ataxia, and the MDS indicated a BIMS score of 13.
Failure to Provide Adequate Supervision During Bed Care
Penalty
Summary
The facility failed to ensure adequate supervision and implementation of interventions to prevent accidents for one resident with a history of falls. The resident was admitted with anoxic brain injury and had severely impaired cognitive skills for daily decision making. The resident was also documented as totally dependent for bed mobility and toileting assistance, and the fall care plan noted that the resident flailed and thrashed his arms during care and at times when awake by himself. Staff interviews confirmed the resident was high risk for falls and that his room door could not be kept open because the roommate would not allow it, limiting visibility from the hallway. Two fall events were documented in which the resident was found on the floor near the bed, including one after staff reported the resident rolled off the bed while care was being provided. During the later event, a CNA stated she was providing care, had raised the bed, locked it, and was holding the resident when he jerked and rolled off the bed onto his buttocks. The CNA acknowledged she did not check the care plan to determine how much assistance was needed and stated staff had always used one person, although she agreed two staff would have been appropriate due to the resident’s combative behaviors. The DON confirmed there was no review of the fall to determine the root cause and no interventions were put into place to prevent recurrence, and also confirmed that if the resident fell out of bed while one aide was providing care, the number of staff should have been increased to two.
Failure to Secure Indwelling Catheter
Penalty
Summary
The facility failed to provide a catheter securement device for Resident #4, who had an indwelling catheter. During observation of catheter care by CNA #2, it was noted that no securing device was in place for the catheter. CNA #2 stated that the device was required to secure the catheter in place and that it must have fallen off. The DON later confirmed that the catheter securing device should be in place for each resident with an indwelling catheter and acknowledged that the facility failed to have a securing device in place for Resident #4. Record review showed Resident #4 had been admitted to the facility and had a BIMS score of 9, indicating moderate cognitive impairment.
Failure to Provide Ordered Nutritional Support for a Resident with Significant Weight Loss
Penalty
Summary
The facility failed to ensure adequate nutritional support and to implement physician-ordered interventions for a resident with significant weight loss. Resident #1 had diagnoses including acute ischemic stroke, dysphagia related to a recent stroke, vascular dementia, and risk for malnutrition, and the MDS showed a BIMS score of 6, indicating severe cognitive impairment. Facility policy required monitoring of weight and nutritional status and dietitian consultation when weight loss exceeded 5% in one month or 10% in six months. The resident’s weights showed a decline from 135 lbs. to 119 lbs. over six months, and from 132 lbs. to 119 lbs. over three months, reflecting significant weight loss. Meal intake records from late February through late March showed a consistent pattern of poor oral intake, with multiple entries of 0%, less than 25%, and meal refusals. The supplement flow sheet showed no documentation that the resident received the ordered supplement. The RD documented that the resident was willing to try chocolate Glucerna and later stated the resident did not like the pureed diet or Glucerna; however, review of the physician orders showed the Glucerna order was entered for only three days and then stopped. The RD confirmed there was no documentation showing the resident received the supplement and that the resident did not get the recommended nutrients and protein that were ordered.
Failure to Assess and Monitor Bed Rail Safety
Penalty
Summary
The facility failed to ensure the safe use, assessment, and ongoing evaluation of bed rails for Resident #65 and did not identify and remove a known entrapment hazard. The resident was observed lying in bed awake and non-verbal with the bed against the wall, one-half upper side rails on both sides, and a fall mat on the floor. Record review showed that after a significant event on 3/3/26, the resident was found halfway on the bed with his legs and arms on the protective mat and his face flipped over into the mattress against the rail, with his nose and mouth between the mattress and rail. The DON later confirmed the resident was at greater risk for side rail entrapment and suffocation than from falls and stated the bed rails should have been immediately removed. Resident #65 had a diagnosis of anoxic brain injury and was severely cognitively impaired on the MDS, which increased his inability to protect himself from harm. The resident’s fall care plan noted that he flailed and thrashed his arms during care and at times when awake. An LPN stated the resident was a high fall risk, was contracted, rocked side to side when wet or in pain, and could not use the side rails for bed mobility or reach/grab them for turning and repositioning. The side rail evaluation dated 3/3/25 stated the resident was using the rails for positioning or support and wanted them raised, but it was not updated after the fall and significant change in condition. The MDS nurse confirmed she was responsible for quarterly updates to the side rail assessment and that this was not being done.
Unsecured medications and treatment solutions left accessible
Penalty
Summary
The facility failed to ensure medications and treatment solutions were secured and not accessible to the resident for three of four survey days. Facility policy titled Medication Administration, revised 3/11/24, stated that no medications should be left in the resident's room and that storage of medications and associated products should be secure, such as in a locked drawer or cabinet, or under constant surveillance. During observation in room C3, surveyors found four bottles of Dakin's solution quarter-strength, with two bottles sitting on a table beside the bed and two in a pink pail by the sink. Other items on the counter by the sink included a bottle of ethyl alcohol 70% and hydrogen peroxide 3%. An LPN confirmed these treatment solutions were left in the room and were readily accessible, and stated they should not be stored there because of the safety risk of a confused resident ingesting or misusing them. Surveyors also observed a medication cart for Halls E and F unlocked and unattended while walking down the hallway. An RN confirmed the cart was unlocked and unattended, and the assigned cart nurse acknowledged she had walked away leaving the cart unlocked. The LPN stated she knew the risks of leaving the cart unsecured and said anyone could access anything in the cart. The DON stated her expectation was that all medication carts remain locked at all times unless the nurse is actively obtaining medications, and that an unlocked and unattended cart could lead to medication diversion by staff, residents, visitors, or others.
Infection Control Practices Not Followed
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when staff failed to maintain effective infection control practices during observations on the unit. A clean utility cart on A Hall, between rooms A9 and A11, was observed uncovered with clean supplies exposed, and resident gowns stored on the bottom shelf had tie strings and fabric touching the floor. CNA #3 confirmed the cart should always be covered and that the gowns touching the floor were unsanitary and could contribute to infection transmission. Further observation outside room [ROOM NUMBER]A showed Enhanced Barrier Precautions and Contact Isolation signage on the door, but CNA #3 and NA #4 entered the room without donning PPE, including a gown. When exiting, NA #4 was observed holding soiled linen against her body without a barrier bag, and neither aide had on a gown. CNA #3 confirmed both residents in the room were under precautions and that they had provided care for the resident in bed B without wearing a gown. The Infection Preventionist and DON both confirmed that clean linen carts must be covered and that staff caring for residents under EBP or contact precautions are required to wear the appropriate PPE, including a gown.
Failure to Complete Wound Care Treatments as Ordered
Penalty
Summary
The facility failed to ensure that wound care treatments were completed as ordered for one of three residents reviewed for wound and skin care. Specifically, a resident with diabetic venous ulcers and other comorbidities had physician orders for dressing changes to a left lower leg ulcer to be performed twice daily. Documentation revealed that the second daily dressing change was not completed or documented thirty-five times over a period of just over a month. Observations and interviews confirmed that the resident often did not receive dressing changes at night and sometimes during the day, and that the dressing was found saturated and soiled, with drainage noted on the resident's pillowcase. The treatment nurse confirmed the missed treatments and acknowledged that wound care was not consistently performed as ordered, especially during night shifts and weekends when the treatment nurse was not present. The resident's wound was documented as worsening, with a significant increase in size over a two-month period. The treatment nurse and Assistant DON both confirmed that failure to complete wound care as ordered could lead to worsening wounds. The DON was aware of concerns regarding incomplete treatments but was not aware of the extent of the issue. The resident was cognitively intact and had a history of chronic kidney disease and lower extremity edema, with a medical note indicating that vascular surgery was not recommended and that an above-the-knee amputation would eventually be required.
Failure to Complete Wound Care Treatments as Ordered
Penalty
Summary
The facility failed to ensure that wound care treatments were completed as ordered for two residents with stage 4 pressure injuries. For one resident with paraplegia and a stage 4 pressure injury on the right upper leg, wound care orders required daily treatment, but documentation showed that treatments were missed on five occasions over a one-month period. The resident confirmed that there had been several instances in the past month when her wound care was not completed as ordered. This resident was cognitively intact, as indicated by a BIMS score of 15. Another resident with metastatic pelvic disease and a stage 4 pressure injury of the coccygeal region had wound care orders for treatment twice daily. Review of treatment flow sheets revealed that the required wound care was not documented as completed on nine occasions within the same timeframe. Interviews with the ADON and DON confirmed awareness of issues with wound care treatments not being completed, though the DON was not aware of the full extent of the problem and could not provide a reason for the missed treatments.
Failure to Implement Care Plan for Dependent Resident with Wound Vac
Penalty
Summary
The facility failed to implement and follow the care plan for a dependent resident who required assistance with activities of daily living (ADLs) and had a negative pressure wound therapy system (wound vac) in place. The resident, who had end stage renal disease on dialysis, decreased mobility, generalized weakness, and severe cognitive deficits, was observed multiple times wearing the same clothes from the previous day, including after returning from medical appointments and while sleeping. Interviews with the resident, complainant, and staff confirmed that the resident was not changed into bed clothes at night, despite having pajamas and gowns available, and that this was not consistent with her preferences or previous habits prior to admission. Additionally, the resident's wound vac, which was ordered to be on continuous suction, was repeatedly found not to be hooked up to suction as required. Observations showed the wound vac tubing attached to the dressing but not connected to suction, and the pump was found unplugged and not in use. Staff interviews confirmed that the wound vac was supposed to be portable and remain on suction at all times, and that failure to do so was not in accordance with physician orders. The wound vac was also not taken with the resident to appointments as required, and alternative dressings were not consistently applied when the wound vac was off. The care plan for the resident included specific interventions for both ADL assistance and wound care, but these were not consistently implemented by staff. The facility's own policy required that care plans be properly developed and implemented, yet staff failed to ensure the resident was changed into appropriate clothing for bed and that the wound vac was maintained as ordered. Multiple staff members, including the DON, RN, and treatment nurse, acknowledged these lapses in care and confirmed that the care plan was not followed.
Failure to Assist Dependent Resident with Bedtime Clothing Change
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living for a dependent resident who was unable to change her own clothes. Despite facility policy requiring residents' clothing to be changed daily and when soiled, staff did not assist the resident in changing from her day clothes into pajamas or gowns before bed. Multiple observations and interviews confirmed that the resident frequently slept in her regular clothes, and staff did not offer or provide help to change her into bed clothes, even though she expressed a preference for sleeping in pajamas and had them available. The issue was reported to facility administration multiple times but was not addressed. The resident involved had a history of Type 2 Diabetes Mellitus, hypertension, end-stage renal disease on dialysis, impaired mobility, and required assistance with all activities of daily living. Her cognitive assessment indicated severe deficits, and she was dependent on staff for personal hygiene and dressing. Staff interviews confirmed awareness of the requirement to change residents into bed clothes, yet the resident was repeatedly left in her day clothes overnight, contrary to both her wishes and facility policy.
Failure to Maintain Continuous Wound Vac Suction as Ordered
Penalty
Summary
The facility failed to provide wound care treatment consistent with professional standards of practice for a resident with a surgical wound following the removal of an infected fistula. The resident had a wound vac ordered to be applied at 120 mmHg continuous suction, with a PRN order for a wet to dry dressing if the wound vac was not in use. Multiple observations and interviews revealed that the wound vac was frequently not hooked up to suction as ordered, including after the resident returned from a doctor's appointment and during various times throughout the day. The wound vac pump was found unplugged and not attached to the resident, and the canister was not present during outings, despite the device being portable and equipped with a battery pack. Staff interviews confirmed that the wound vac was supposed to be in use and on suction at all times, except for brief periods such as during showers or if a wet to dry dressing was applied. Both the RN and Treatment Nurse acknowledged that the wound vac was left off on several occasions, and the Treatment Nurse reported having observed and reported this issue previously. The Interim DON and Nurse Practitioner also confirmed that the wound vac should have been continuously in use, and that staff were responsible for ensuring it was functioning as ordered. The resident did not refuse the treatment, and there was no documentation of discomfort or refusal. The resident's medical history included Type 2 Diabetes Mellitus, hypertension, end-stage renal disease on dialysis, impaired mobility, and a recent abscess of the left upper extremity. The care plan and physician orders specified the use of the wound vac at all times, with clear instructions for alternative dressing if the device was not in use. Despite these orders and the resident's complex medical needs, the facility did not consistently follow the prescribed wound care protocol, as evidenced by multiple staff and family reports, as well as direct observation.
Improper Storage and Loss of Refrigerated Controlled Medications
Penalty
Summary
A deficiency occurred when medications requiring refrigeration, specifically four vials of Ativan injectable, were not properly secured during the defrosting and subsequent removal of a medication room refrigerator. The facility's policy required that all medications be appropriately stored and remain with a licensed individual at all times when removed from designated storage. However, during the defrosting process, one LPN removed only a single vial of Ativan for immediate use, leaving the remaining four vials in a locked box inside the refrigerator. There was a miscommunication between the two LPNs involved, with each believing the other had removed all the medications. The refrigerator, which contained the locked box with the four vials of Ativan, was then taken outside by one of the LPNs after it was found to be malfunctioning. Maintenance staff, unaware that medications remained inside, later transported the refrigerator to a landfill as scrap. The locked box containing the Ativan was not retrieved before disposal, and the medications were not accounted for until the following day, when staff realized the refrigerator was missing and the vials could not be recovered. Interviews with the Interim DON, Interim Administrator, and the LPNs involved confirmed that the Ativan vials were not properly removed and secured prior to the refrigerator being taken out of the facility. Documentation and time card records corroborated the sequence of events, showing that the medications were left unattended and ultimately lost due to failed communication and lack of adherence to medication storage protocols.
Inaccurate PBJ Staffing Data Submission Due to Manual Entry Errors
Penalty
Summary
The facility failed to submit accurate direct care staffing information into the Payroll Based Journal (PBJ) system for one of four quarters reviewed, specifically the fourth quarter of 2024. Record review showed that the PBJ Staffing Data Report indicated excessively low weekend staffing during this period. However, interviews with the Assistant Administrator and the Managerial Assistant revealed that the facility was not actually short-staffed during weekends or weekdays. The Assistant Administrator was unsure why the PBJ report reflected low staffing and confirmed that shifts were sufficiently covered. Further investigation found that the Managerial Assistant, who was responsible for entering staffing data into the PBJ system, was new to the position during the fourth quarter. She explained that while hourly staff hours were automatically recorded, salaried staff hours worked outside their normal schedule had to be entered manually. She acknowledged that due to her inexperience at the time, it was likely that the data for salaried employees was not entered accurately, resulting in the inaccurate PBJ submission.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to provide a clean, safe, and homelike environment for its residents, as evidenced by multiple deficiencies observed in several rooms. In room A-12, there were multiple areas of missing paint, dead bugs in the ceiling light fixture, water stains on ceiling tiles, broken wood molding with a sharp point, and window blinds in disrepair. The Environmental Service (EVS) Manager confirmed these issues and acknowledged that the process for repairs was not followed, resulting in the room not being maintained in good repair. In room C-14, a foul odor and a dried yellow substance were observed on the bathroom floor, indicating that the room was not cleaned as required. The Assistant Administrator and EVS Manager confirmed the oversight and acknowledged that the room was not a clean, homelike environment for the resident. Similarly, room E-3 had paint scraped off the wall, peeling sheetrock, and a broken electrical wall outlet cover. Maintenance staff confirmed these issues and noted that no work order had been received for the room. Additional observations in rooms B-7, B-9, and B-15 revealed dead insects in ceiling light coverings and a black and white substance on the air/heat unit vent. The EVS Manager confirmed these findings and explained that housekeeping was responsible for daily cleaning, while maintenance was responsible for changing and cleaning filters. The facility had recently implemented 'angel rounds' to identify environmental concerns, but these issues had not been addressed, indicating a failure to ensure a clean, safe environment for residents.
Failure to Facilitate Resident's Right to Vote
Penalty
Summary
The facility failed to honor a resident's right to vote in the 2024 election. A cognitively intact resident, who had lived at the facility for over a year, reported that she was registered to vote in a different county and was waiting for staff to provide her with the necessary forms to participate in the election. Despite her expressed interest and history of voting, staff did not provide her with the required assistance, and she ultimately did not get to vote. The Social Services staff member acknowledged that she did not individually approach residents about their desire to vote, instead informing some residents during a council meeting that they needed to come to her if they wished to vote. The resident in question did not approach Social Services, and the staff confirmed that they should have directly spoken with her regarding her voting wishes. The Administrator also confirmed that the facility should have ensured the resident was able to vote.
Inaccurate MDS Coding for Residents with Serious Mental Illness
Penalty
Summary
The facility failed to accurately complete Section A of the Minimum Data Set (MDS) for two residents who had been identified by the state PASRR process as having a serious mental illness. For both residents, the PASRR Summary Findings documented diagnoses of serious mental illnesses, including schizophrenia, bipolar disorder, mood disorder, and post-traumatic stress disorder. Despite this, the MDS assessments for these residents were coded as 'No' in response to whether the resident was considered by the state Level II PASRR process to have a serious mental illness or related condition. The inaccuracy was attributed to a lack of communication between Social Services (SS) and the MDS department. The MDS Nurse reported that she was informed by SS that there were no residents with a Level II PASRR, leading to the incorrect coding. SS later confirmed awareness that the two residents had received Level II PASRR determinations but did not relay this information to the MDS department. This failure resulted in the residents' MDS assessments not reflecting their true mental health status as determined by the PASRR process.
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A resident with advanced dementia and severe cognitive impairment sustained a bruised left eye and facial bruising after being struck by a CNA. The CNA initially claimed the injury occurred accidentally while pushing the resident to a dining table and denied hitting the resident, but an LPN and another CNA reported that the resident stated she had hit the CNA and was hit back in the eye, demonstrating a slapping motion. Nursing documentation described left orbital ecchymosis, bruising along the bridge of the nose and cheek, tenderness, minimal edema, and the resident’s complaint of soreness, confirming a significant injury resulting from the physical abuse.
The facility failed to protect residents’ right to a dignified and comfortable environment when it did not effectively manage one cognitively impaired resident’s ongoing nighttime yelling, which repeatedly disrupted the sleep of two cognitively intact residents. Staff, including a CNA, the DON, and the Administrator, were aware that this resident, diagnosed with dementia and psychosis, frequently yelled and screamed at night while often sleeping during the day. Progress notes documented nighttime hollering, and interviews confirmed that the disruptive behavior persisted over time, interfering with other residents’ ability to rest.
Surveyors found that the facility failed to protect two residents’ rights to dignity and privacy during routine care. One resident, with moderate cognitive impairment and dependent for toilet hygiene, was observed receiving incontinence care while uncovered, with the room door open and the privacy curtain only partially drawn, allowing visibility into the hallway despite facility policy requiring full privacy. Another resident, dependent for eating and with hemiplegia after a stroke, was assisted with lunch by a CNA who stood over the resident instead of sitting at eye level as required by the facility’s feeding skills checklist. Staff interviews, including with CNAs, an LPN, the DON, and the Administrator, confirmed that existing policies and in-service training directed staff to provide privacy during incontinence care and to sit beside residents when assisting with meals to ensure dignified care.
A resident with epilepsy, skin infection, an upper arm wound, gastrostomy status, and moderate cognitive impairment was observed twice resting in bed with a lunch tray while the call light was not within reach—once on the floor under the bed and once hanging behind the mattress, out of sight. The resident reported being able to use the call light but not knowing where it was. Staff, including CNAs, an LPN, the DON, and the Administrator, stated that call lights are expected to be left within residents’ reach and that training and competencies address this requirement, but there was no specific written policy on call light placement.
A resident with moderate cognitive impairment, dependent for toilet hygiene and with multiple medical conditions, was observed receiving incontinent care in which a CNA removed a urine-soaked brief, changed the bed sheet, and applied a clean brief without performing any required perineal cleansing of the front or back. Facility policy and the peri-care skills checklist specified that male residents must have the perineal area, including the penis, scrotum, and inner thighs, washed, rinsed, and dried during incontinent care. The CNA later acknowledged having been trained and competency-checked on this procedure and knowing cleansing was required. Other staff, including a CNA supervisor, an LPN, the DON, and the Administrator, confirmed that proper incontinent care includes full perineal cleansing in addition to brief changes, establishing that the observed omission did not follow facility policy or professional standards intended to prevent UTIs.
Surveyors found that staff failed to follow infection control practices during PEG tube and wound care. Two residents with PEG tubes had sites with visible brown, crusted or yellowish drainage that had not been cleaned for several days, despite physician orders for daily cleansing and, when indicated, dressings. In another case, a CNA provided peri-care for stool and then assisted with a stage IV sacral pressure ulcer dressing change without changing gloves or performing hand hygiene, contrary to facility policy and staff expectations for aseptic technique.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment when a resident’s room contained odorous soiled linens left on the floor and later placed on furniture with clean clothing, and the bed was made with torn linens exposing the mattress. Other residents reported that housekeeping did not clean under beds, and multiple large dead roaches were repeatedly observed under several beds, with one resident stating he often disposed of dead roaches himself. Residents also reported refusing to use the north shower room due to dirty clothing, feces, and residue on shower chairs and floors; an observation confirmed the presence of soiled clothing, a soiled brief, and unidentified substances on the shower chair and floor, despite staff acknowledging that CNAs were expected to clean and sanitize the shower room after each use.
The facility failed to maintain an effective pest control program, as evidenced by repeated observations of roaches and other insects in multiple resident rooms and common areas. Surveyors found gnats and dead roaches under beds, while several residents reported seeing roaches on ceilings, walls, and floors, including roaches falling onto them at night and having to remove dead roaches themselves. A family member reported bringing her own roach spray due to concerns about roaches in a loved one’s room. During a Resident Council meeting, roaches were seen crawling across the floor, and residents stated that roaches were commonly observed throughout the building. Although the contracted pest control provider reported monthly service focused mainly on entry points and exterior areas and facility staff described processes for reporting pests, the persistent roach activity showed the program was not effectively preventing or controlling pests.
A resident with multiple chronic conditions, who relied on phone contact with a seriously ill significant other, lost access to private communication after her personal cell phone was broken and sent out for repair. Facility policy guarantees residents access to a telephone and private communication, but there was no cordless phone available on the relevant hall, and staff, including the DON, SSD, and Administrator, confirmed there was no convenient method for residents on that hall to make private calls without arranging to use a staff office. This resulted in the resident having no readily available, private telephone option.
A resident with heart failure, chronic kidney disease, hypertension, moderate cognitive impairment, and total dependence on staff for personal and toilet hygiene reported difficulty obtaining assistance with ADLs. Observation revealed the resident had ten long, dirty fingernails extending several millimeters beyond the fingertips with black material underneath, and the resident stated they needed cleaning and cutting. An LPN confirmed the nails were too long and dirty, acknowledged that nursing staff were responsible for daily and weekly fingernail checks and for providing fingernail care as part of ADLs, and noted that such nails could cause skin damage or scratches. The DON and Administrator both confirmed that personal hygiene and grooming are part of ADLs and are expected to be provided for all residents dependent on staff.
Failure to Protect Cognitively Impaired Resident From Physical Abuse by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse, resulting in the resident being struck in the eye by a CNA. Facility records show that a CNA reported to an LPN that the resident had a bruised left eye and initially stated the injury may have occurred while pushing the resident to the dining table due to the resident’s short, stooped posture. The CNA also reported that the resident used a racial slur toward her and that she verbally responded but denied striking the resident. However, subsequent interviews and the facility’s investigation determined that the resident’s injury was not caused by accidental contact with the dining table. Interviews with staff revealed conflicting accounts that led to the conclusion that the resident had been hit. An LPN stated that the resident reported being hit in the eye by the CNA and that another CNA heard a commotion and later observed bruising to the resident’s left eye. When this second CNA asked what happened, the resident reported that she hit the CNA and was hit back in the eye, while making a motion consistent with a slap. The LPN confirmed that the resident gave a similar account to her, indicating that the CNA had physically struck the resident. The resident involved was admitted to the Memory Care Unit with diagnoses including Alzheimer’s disease, cognitive communication deficit, and unspecified dementia with behavioral disturbance, and had a BIMS score of 5 indicating severe cognitive impairment. A nursing progress note documented an acute follow-up assessment of left orbital ecchymosis, describing a dark red circular bruise to the left eye region, dark purple bruising along the lateral bridge of the nose extending to the superior left cheek, tenderness on palpation, minimal edema, and the resident’s complaint that the area was sore. Due to advanced Alzheimer’s disease, the resident was unable to reliably express additional symptoms, but the documented physical findings supported that the resident sustained a significant injury to the eye area as a result of being struck by the CNA.
Failure to Protect Residents’ Right to Rest Due to Unmanaged Nighttime Yelling
Penalty
Summary
The deficiency involves the facility’s failure to ensure a dignified and comfortable environment by not effectively addressing ongoing disruptive nighttime behaviors of one resident that interfered with other residents’ ability to rest. Resident #1, admitted with diagnoses including Psychosis and Dementia and a BIMS score of 4 indicating severely impaired cognition, had documented episodes of hollering and yelling during nighttime hours, as noted in progress notes on 3/12/26 and 3/13/26. Interviews with cognitively intact residents, Resident #2 and Resident #3 (both with BIMS scores of 15), revealed that they frequently experienced disrupted sleep due to Resident #1 yelling loudly at night, while the environment was generally quiet during the day. Staff interviews confirmed awareness of the pattern of behavior. CNA #1, who worked both day and night shifts, reported that Resident #1 frequently yelled and screamed at intervals throughout the night and was generally quiet and often slept during the day, with staff assisting the resident out of bed into a geri-chair during both day and nighttime hours. The DON acknowledged the facility was aware of Resident #1’s increased nighttime yelling and extended daytime rest, attributing it to the resident’s Dementia and Psychosis, and stated that interventions such as monitoring, repositioning, offering care, and attempts at redirection had not stopped the behaviors. The Administrator also confirmed awareness of concerns that nighttime noise from Resident #1 affected other residents’ ability to rest. Despite this awareness and ongoing complaints from other residents, the disruptive nighttime yelling continued, resulting in a failure to uphold residents’ rights to a dignified existence and a comfortable environment.
Failure to Ensure Privacy and Dignified Care During Incontinence Care and Feeding
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were treated with dignity and provided privacy during care, as required by resident rights policies and skills checklists. The facility’s Nursing Facility Resident Rights policy guaranteed residents the right to be treated with dignity, courtesy, and respect, and to have privacy during personal care. Facility skills checklists for feeding and peri/incontinent care specified that staff should sit facing residents at eye level when feeding and provide privacy by drawing curtains and closing doors during incontinence care. For Resident #2, surveyors observed a CNA providing incontinent care without closing the resident’s room door and with the privacy curtain only partially drawn. From the surveyor’s position at the bottom right corner of the bed, it was possible to see into the hallway while the resident was uncovered and exposed. Resident #2’s records showed admission with diagnoses including epilepsy, infection of the skin and subcutaneous tissue, an open wound of the left upper arm, and gastrostomy status. A recent MDS assessment documented a BIMS score of 11, indicating moderate cognitive impairment, and that the resident was dependent for toilet hygiene. The CNA later confirmed awareness that incontinence care required provision of privacy and that she had been trained and competency-checked on this requirement. For Resident #3, surveyors observed a CNA assisting the resident with eating while standing over the resident rather than sitting beside her, contrary to the facility’s feeding skills checklist and training. The DON intervened during the observation and instructed the CNA that staff were to sit next to residents while assisting with eating. The CNA stated she had forgotten to sit beside the resident. Resident #3’s records showed recent admission with diagnoses of cerebral infarction (stroke), anemia, and hemiplegia and hemiparesis affecting the right dominant side, and a baseline care plan indicating the resident was dependent for eating. Other staff interviews, including with a CNA supervisor, an LPN, the DON, and the Administrator, confirmed that staff were trained at least monthly on residents’ rights, respectful and dignified care, provision of privacy during incontinence care, and the expectation that staff sit beside residents when assisting with eating.
Failure to Maintain Accessible Call Light for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was maintained within reach as required by the facility’s feeding skills checklist. The skills checklist for feeding a resident specifies that staff must leave the call light within the resident’s reach after feeding. For Resident #2, surveyors observed on two separate occasions that the call light was not accessible. On one observation, the resident was awake in bed with a lunch tray on the overbed table, and the call light was found lying on the floor under the head of the bed. The resident stated he could use his call light but did not know where it was. On a subsequent observation, Resident #2 was again in bed with a lunch tray in front of him, and the call light was hanging behind the mattress at the head of the bed, out of his sight and reach. The resident again stated he could use the call light but did not know where it was. Record review showed the resident had epilepsy, an infection of the skin and subcutaneous tissue, an open wound of the left upper arm, gastrostomy status, and a BIMS score of 11 indicating moderate cognitive impairment. Staff interviews with CNAs, an LPN, the DON, and the Administrator confirmed that call lights were expected to be within residents’ reach and answered timely, and that staff had received in-service training and competency checks on leaving call lights within reach. The Administrator also confirmed there was no specific written policy regarding call light placement.
Failure to Provide Required Perineal Cleansing During Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to provide incontinent care in accordance with its own peri-care policy and professional standards of practice for a male resident who was dependent for toilet hygiene. The facility’s written policy for peri/incontinent care for male residents, revised in January 2023, required cleansing of the perineal area starting at the urethra and working outward, including washing and rinsing the penis, scrotum, inner thighs, and perineal area front and back, followed by thorough drying. Record review showed the resident had diagnoses including epilepsy, infection of the skin and subcutaneous tissue, an open wound of the left upper arm, and gastrostomy status, and a Quarterly MDS with a BIMS score of 11 indicating moderate cognitive impairment, with the resident assessed as dependent for toilet hygiene. On the observed date and time, CNA #1 provided incontinent care to this resident by removing a wet urine-soaked brief, changing the fitted sheet, and applying a clean, dry brief without cleansing the resident’s perineal area, front or back, contrary to facility policy. During a subsequent interview, CNA #1 acknowledged she had received in-service training and competency check-offs on peri-care and knew she was supposed to cleanse the perineal area but did not do so, stating she was nervous. Additional interviews with CNA #2 (CNA supervisor and scheduler), an LPN, the DON, and the Administrator confirmed that staff were trained using the Peri Care–Incontinent Care Skills Checklist and that proper incontinent care includes cleansing the perineal area, front and back, in addition to changing the brief. The failure to perform the required cleansing during incontinent care constituted the cited deficiency related to prevention of urinary tract infections.
Failure to Maintain Infection Control Practices During PEG Tube and Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program by not maintaining aseptic technique and not providing ordered dressing changes for residents with PEG tubes and a sacral pressure injury. Facility policies on infection control and clean dressing changes required wound care to be provided in a manner that decreases the potential for infection and cross-contamination, including removal of soiled dressings with gloves, discarding gloves, performing hand hygiene, and donning clean gloves before continuing care. The peri-care audit tool also required glove removal, hand hygiene, and re-gloving after peri-care. These standards were not followed during multiple observed care episodes. For one resident with a PEG tube and diagnoses including Alzheimer’s disease, functional quadriplegia, and gastrostomy status, surveyors observed the PEG tube site without a dressing and with a yellowish-brown substance beneath and around the external skin disk extending about one-fourth inch onto surrounding skin. A CNA and an LPN both confirmed there was no dressing in place and acknowledged the drainage at the site. The LPN stated PEG tube site care should be completed daily and as needed for increased drainage and acknowledged that, with no dressing and the amount of drainage present, there was no way to tell when the site was last cleaned. Record review showed a physician order, effective several months prior, for daily cleansing of the PEG tube stoma with normal saline, patting dry, and applying a dry drain dressing to avoid skin breakdown. For another resident with severe protein-calorie malnutrition and gastrostomy status, the PEG tube site was observed with thick brown, crusted substance beneath the external skin disk extending approximately one-half to three-fourths of an inch to the surrounding area. The resident reported the site had not been cleaned in about three days and later stated they might have to clean it themselves. Follow-up observations confirmed the site remained unclean with visible drainage, and an LPN and the DON both confirmed the presence of thick, brown drainage and that the site had not been cleaned in several days, despite an order for daily cleansing with soap and water, rinsing, patting dry, and leaving open to air or applying a dry dressing if drainage was present. In a separate observation involving a resident with a stage IV sacral pressure ulcer and severe cognitive impairment, a CNA provided peri-care for stool soiling, then immediately assisted with wound care using the same gloves worn during peri-care, without performing hand hygiene or changing gloves. The CNA, treatment nurse, DON, and ADON all acknowledged that hand hygiene and glove change should have occurred between peri-care and wound care and that this represented an infection control concern.
Failure to Maintain Clean Resident Rooms and Shower Facilities
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by its Resident Rights & Quality of Life Policy. For one resident, surveyors observed a bag of odorous soiled linens resting on the floor of the room, and the resident’s bed was made with a bedspread that had a football-sized hole exposing the mattress. The resident, who was cognitively intact with a BIMS score of 14 and had Type 2 Diabetes Mellitus, reported that it was not unusual for bags of soiled linens to be left on the floor and for bedding to be damaged. A CNA confirmed that soiled linens were commonly left in bags on the floor after morning care and that torn bedding should not be used, and later placed the bag of soiled linens on the resident’s furniture where his clean clothing was hanging. The resident remained upset the following day, and a dead roach was observed under his bed near the headboard. Additional deficiencies were identified in other resident rooms. One resident with End Stage Renal Disease and a severely impaired cognition (BIMS score of 5) reported that housekeeping did not clean under the bed; surveyors observed three large dead roaches under the bed, which remained there the following day. When the Housekeeping Supervisor later observed the room, five dead roaches were present under the bed, and he stated the area should not have been in that condition. Another resident, with a diffuse traumatic brain injury and a moderately impaired cognition (BIMS score of 10), reported frequently picking up and disposing of dead roaches himself because staff did not remove them, and a large dead roach was observed under his bed. The facility also failed to maintain a clean and sanitary north shower room. During a Resident Council interview, multiple cognitively intact and moderately impaired residents reported refusing to use the shower room due to cleanliness concerns, including observations of dirty clothing, feces, and residue on shower chairs and floors. A housekeeper stated that while she cleaned the shower rooms multiple times a day, CNAs were responsible for cleaning and sanitizing the shower room after each use and that she had observed occasions when CNAs failed to do so. A subsequent observation of the north shower room revealed soiled clothing, including a soiled brief, on a shower chair, a yellow fluid-like substance on the floor and shower chair, and a white powdery substance on the floor, with no staff present. The Social Services Assistant, DON, and Administrator each acknowledged that staff were expected to clean and sanitize the shower room after each use.
Ongoing Roach Activity Demonstrates Ineffective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program as required by its pest control policy dated 9/1/2014, which states the center will maintain an ongoing program to keep the building free of insects and rodents. Surveyors observed multiple instances of roach and insect activity in resident rooms and common areas. In one cognitively intact resident’s room, gnats were seen flying and a dead roach was later found under the bed near the headboard. Another resident’s room contained three large dead roaches under the bed on two consecutive days; this resident reported that roaches were regularly seen in the room, especially at night, crawling on the ceiling and falling onto him and his roommate, and that staff had been notified but he had not seen staff respond to assess or treat the issue. A third resident reported seeing roaches on the ceiling and under the bed and stated he often removed dead roaches himself because staff did not; a large dead roach was observed under his bed. A family member of another resident reported feeling it was necessary to bring her own roach spray due to concerns about roaches in the resident’s room and stated she was told she could not keep the spray in the room, expressing concern that the roach problem needed to be addressed. During a Resident Council meeting, two large roaches were observed crawling across the floor, and residents reported that roaches were commonly seen in rooms and common areas, including on walls, ceilings, and floors, particularly at night. The contracted pest control provider reported he provides monthly services, focusing on different areas each visit, primarily treating entry points and exterior areas, and stated he had not personally observed roaches and received only occasional complaints. Facility leadership, including the housekeeping supervisor, DON, and Maintenance Director, described expectations that staff report pest sightings and that pest control services are available monthly and as needed, but the ongoing presence of roaches and dead insects in resident rooms and common areas demonstrated that the pest control program was not effectively preventing or controlling pests.
Failure to Ensure Resident Access to Private Telephone Communication
Penalty
Summary
The facility failed to ensure a resident’s right to reasonable access to and privacy in the use of a telephone for communication. Facility policy on Resident Rights, revised December 2016, states that residents are guaranteed access to a telephone, mail, and email, and the ability to communicate in person and by mail, email, and telephone with privacy. Resident #1 was admitted on 12/18/24 with diagnoses including Sjogren syndrome, rheumatoid arthritis, chronic kidney disease, and morbid obesity. During an interview, the resident reported that she had dropped and broken her personal cellular telephone, which she had used for private communication, and that the facility did not have any telephone that was convenient for her to use privately. She stated that no staff had offered her the use of a staff office or any other mechanism for private communication, and she was upset because she relied on telephone contact with her significant other, who had cancer and was unable to visit. Observations and staff interviews confirmed the lack of accessible, private telephone options for residents on South Hall. An observation on the 100 Hall revealed there was no cordless telephone available for resident use. The DON confirmed that the facility did not have a method to provide residents on South Hall with private communication without first making arrangements or an appointment to use a staff office, and that the cordless telephones in the facility did not have sufficient range to reach South Hall. The SSD confirmed there were no cordless telephones at the South Hall nurses’ station that could be taken to residents’ rooms and acknowledged that Resident #1’s cell phone had been broken and sent out for repair. The Administrator also confirmed that residents on South Hall did not have a method for private communication without prior arrangements and acknowledged that access to private communication is a guaranteed resident right.
Failure to Provide Adequate ADL Assistance for Personal Hygiene
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) to maintain personal hygiene for one resident who was dependent on staff for care. Facility policy on ADLs, revised March 2018, stated that residents unable to carry out ADLs independently would receive services necessary to maintain good grooming and personal and oral hygiene. Record review showed the resident was admitted with heart failure, chronic kidney disease, and hypertension, had a BIMS score of 12 indicating moderate cognitive impairment, was always incontinent of bowel and bladder, and required substantial/maximal assistance for personal hygiene and was dependent for toilet hygiene. A complainant reported that the resident had expressed difficulty getting staff to provide assistance with ADLs. During an observation and interview with the resident, accompanied by an LPN, the resident reported ongoing difficulty obtaining assistance with ADLs. The surveyor observed that the resident had ten long, dirty fingernails protruding 3.0 to 3.5 millimeters past the fingertips, with a black substance beneath all fingernails; the resident stated they needed cleaning and cutting and were too long. The LPN described the fingernails as too long and dirty, confirmed that nursing staff were responsible for checking fingernails daily during care and weekly during body audits, and acknowledged that staff were responsible for providing fingernail care as part of ADLs. The LPN also confirmed that long, dirty, unkempt fingernails had the potential to cause damage or scratches to the resident’s skin. The DON stated she was not aware of any complaints from the resident but confirmed her expectation that ADLs for residents dependent on staff for personal hygiene would be maintained and provided as needed, and that licensed nurses trimmed fingernails for some residents while any nursing staff could clean under fingernails. The Administrator confirmed that personal hygiene and grooming were part of resident ADLs and were expected to be provided for all dependent residents.
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