Reginald P White Nursing Facility
Inspection history, citations, penalties and survey trends for this long-term care facility in Meridian, Mississippi.
- Location
- 1451 North Lakeland Drive, Meridian, Mississippi 39307
- CMS Provider Number
- 25A123
- Inspections on file
- 16
- Latest survey
- October 22, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Reginald P White Nursing Facility during CMS and state inspections, most recent first.
Two CNAs transferred a resident with Parkinson's Disease and moderate cognitive impairment using a mechanical lift without the required four-person assist, resulting in the resident falling backward in a transport chair and complaining of head pain. Both CNAs were aware of the care plan requirements but did not follow them, and facility leadership confirmed this failure constituted neglect.
A resident with Parkinson's Disease and moderate cognitive impairment, who required a four-person assist for Hoyer lift transfers per care plan and physician orders, was transferred by only two CNAs. During the transfer, the resident fell when the transport chair flipped backward, resulting in a complaint of head pain and a subsequent emergency room evaluation. The deficiency was due to staff not following the individualized care plan for safe transfer.
The QAPI Committee failed to sustain corrective actions for infection control, resulting in repeat deficiencies. Two residents were affected when a nurse did not perform hand hygiene or use appropriate PPE during PEG tube medication administration, and an LPN did not follow enhanced barrier precautions or glove-changing protocols during wound care.
Staff failed to follow infection prevention protocols for two residents requiring Enhanced Barrier Precautions. A nurse did not perform hand hygiene or wear a gown during PEG tube medication administration, and an LPN did not change gloves or don a gown during wound care, resulting in contaminated care procedures. These actions did not comply with facility policies for infection control.
A registered nurse failed to verify PEG tube placement before administering medications to a resident with a gastrostomy, despite facility policy requiring this step. The nurse acknowledged the omission during an interview, and the DON confirmed that verification should have occurred to prevent complications. The resident had moderately impaired cognition and physician orders for multiple medications via the PEG tube.
A resident with cognitive and visual impairments was physically abused when a CNA dragged him by his clothing down a hallway while an LPN and other staff failed to intervene or immediately report the incident. Multiple staff witnessed the event, but reporting was delayed and no immediate action was taken to stop the abuse, in violation of facility policy.
A CNA physically abused a resident by dragging them down a hallway by their clothing, an act witnessed by an LPN and other staff who failed to intervene or promptly report the incident. The resident, who has cognitive and visual impairments, was left embarrassed and at risk. Facility policy requiring immediate reporting of abuse was not followed, resulting in Immediate Jeopardy and Substandard Quality of Care.
A resident with cognitive impairment was physically abused by a CNA, who dragged the individual by the neck and clothing. Multiple staff, including an LPN and a housekeeper, witnessed the event but did not immediately report it to the DON or administration as required by policy. The incident was not formally reported until several days later, resulting in delayed assessment and notification to authorities.
A resident with a history of self-injurious behavior and moderate cognitive impairment was physically abused when a CNA, not assigned to the resident, dragged him by his clothing instead of following care plan interventions such as redirection and helmet use. An LPN witnessed the incident but did not intervene or report it as required. The failure to implement the resident's care plan placed the resident and others at risk for serious harm.
Failure to Follow Care Plan During Mechanical Lift Transfer Results in Resident Fall
Penalty
Summary
Staff failed to ensure a resident's right to be free from neglect when two CNAs transferred a resident using a mechanical lift without following the care plan and physician orders, which required a four-person assist for safe transfer. The resident, who had Parkinson's Disease and moderately impaired cognition, was being moved from bed to a transport chair. During the transfer, only two CNAs were present, despite the established requirement for three CNAs and one nurse due to the resident's physical limitations and risk for instability. As a result of this inadequate staffing during the transfer, the resident was seated in the transport chair when it flipped backward, causing the resident to fall to the floor. The resident complained of head pain, though no visible injuries were noted, and was subsequently sent to the emergency room for further evaluation. Both CNAs involved acknowledged awareness of the four-person assist requirement, but one CNA stated that staffing shortages had led to only two people assisting, while the other CNA believed there had been a change in protocol based on a prior meeting. Interviews with facility leadership confirmed that the staff did not provide the necessary care and supervision to ensure the resident's safety during the transfer. The DON and Administrator both acknowledged that the failure to follow the care plan and obtain the required assistance constituted neglect and placed the resident at risk for injury. The incident was reported to the appropriate authorities within the required timeframe.
Failure to Follow Care Plan for Hoyer Lift Transfer Results in Resident Fall
Penalty
Summary
The facility failed to implement a comprehensive care plan intervention for a resident with Parkinson's Disease who required transfer using a Hoyer lift with four-person assistance, as specified in both the care plan and physician orders. Despite the care plan clearly stating that transfers should be performed by three CNAs and one nurse, the resident was transferred by only two CNAs. Both CNAs involved were aware of the four-person assist requirement, but one CNA stated that due to staff shortages, only two people had been assisting, while the other CNA believed the protocol had been changed to a two-person assist based on a prior meeting. During the transfer from bed to transport chair, the resident was seated in the chair when it flipped backward, resulting in a fall. The resident, who had moderately impaired cognition, complained of head pain but had no visible injuries and was sent to the emergency room for evaluation. The incident was classified as a staff violation of the care plan and physician orders, as the transfer was not conducted according to the individualized care plan requirements.
Repeat Infection Control Deficiency Due to Lapses in QAPI Oversight
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to sustain corrective actions to prevent the recurrence of previously cited deficiencies related to infection control practices. Despite having been cited for failing to maintain infection control during wound care in a prior annual recertification survey, the facility was cited again for the same deficiency during the current survey. Record reviews confirmed that the facility had previously received a citation for failing to prevent the possibility of the spread of infection during wound care. During the current survey, staff were again observed not following appropriate infection prevention and control practices for two residents. Specifically, a Registered Nurse did not perform hand hygiene or don appropriate personal protective equipment (PPE) while administering medications through a PEG tube to a resident who required enhanced barrier precautions. Additionally, an LPN failed to follow enhanced barrier precautions and glove-changing protocols during wound care for another resident. These lapses were identified through direct observation, staff interviews, and record reviews, demonstrating a failure to maintain consistent infection control practices as required.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene Protocols
Penalty
Summary
The facility failed to ensure staff adhered to infection prevention and control practices for two residents requiring Enhanced Barrier Precautions (EBP). For one resident with a PEG tube, a registered nurse did not perform hand hygiene between glove changes and failed to don a gown while administering medications, despite the resident's need for EBP. The nurse acknowledged not following protocol, and both the infection preventionist and acting DON confirmed that hand hygiene and gown use were required by facility policy during such procedures. For another resident receiving wound care, an LPN did not wear a gown and failed to change gloves after cleansing a dirty wound bed, applying a clean dressing with contaminated gloves. The LPN admitted to not following EBP and glove-changing protocols, and the DON and infection preventionist confirmed that these steps were necessary to prevent contamination. Both residents had documented medical needs requiring these precautions, and the facility's own policies outlined the required infection control measures that were not followed.
Failure to Verify PEG Tube Placement Prior to Medication Administration
Penalty
Summary
A deficiency was identified when a registered nurse (RN) failed to verify the placement of a Percutaneous Endoscopic Gastrostomy (PEG) tube prior to administering medications to a resident. During a medication administration observation, the RN administered MiraLAX, potassium chloride, and ibuprofen via the PEG tube without confirming its placement, contrary to the facility's policy and professional standards of practice. The RN later acknowledged in an interview that verifying PEG tube placement is necessary to ensure correct positioning and prevent complications. The resident involved had a history of gastrostomy status and physician orders for multiple medications to be administered via the PEG tube. The resident's Minimum Data Set (MDS) assessment indicated moderately impaired cognition. The acting Director of Nursing (DON) confirmed in an interview that the RN should have verified PEG tube placement before administering medications and that failure to do so could result in complications.
Failure to Protect Resident from Physical Abuse and Lack of Timely Staff Intervention
Penalty
Summary
A resident with diagnoses including epilepsy, bipolar disorder, and mild intellectual disabilities, and with a moderately impaired cognitive status and severely impaired vision, was physically abused by a Certified Nurse Assistant (CNA). The incident occurred when the resident was sitting on the floor in the hallway near the nurse's station, engaging in self-injurious behavior by hitting his head and refusing to wear his protective helmet. The CNA, who was not assigned to this resident, dragged the resident by the neck and shoulders of his jacket along the hallway floor and into his room, without attempting to redirect him or offer alternative interventions such as food or water. The abuse was witnessed by multiple staff members, including a Licensed Practical Nurse (LPN) and another CNA, as well as a housekeeper. The LPN observed the CNA dragging the resident and felt it constituted abuse but did not intervene to stop the incident. The LPN attempted to report the event to security and the Director of Nursing (DON), but did not complete the report until her next shift. The housekeeper also witnessed the event but did not report it, assuming others would do so. Surveillance video confirmed the CNA dragging the resident approximately 16-20 feet down the hallway, with the LPN walking beside them and not intervening. Interviews with staff and the resident confirmed the details of the incident. The resident recalled being dragged and expressed embarrassment, though he stated he was not physically hurt. Staff interviews revealed a lack of immediate intervention and delayed reporting of the abuse, despite facility policy requiring immediate reporting and intervention in suspected abuse situations. The failure to protect the resident from physical abuse and the lack of timely intervention and reporting by staff constituted a deficiency in ensuring residents' rights to be free from abuse.
Removal Plan
- The Quality Assurance Committee held an Emergency QA Meeting to discuss the incident.
- The QA committee discussed and approved training provided at the beginning of the shift to all staff on Resident Rights, Suspicion of Abuse, Neglect, Exploitation, Injuries of Unknown Origin, and misappropriation of funds/Property to Individuals Receiving Services/Residents and Resident #1 behavior Intervention protocol.
- Abuse/Neglect Policy & Adherence to Care Plan will be monitored.
- Quality of correction will be monitored by observing interventions and interactions with patients by Nurse Manager and four Nurse Supervisors.
- Findings will be reported to QAPI (Quality Assurance Performance Improvement).
- All supervisors began training all oncoming staff before the start of their shift on Resident Rights, Suspicion of Abuse, Neglect, Exploitation, Injuries of Unknown Origin, or Misappropriation of Funds/Property to Individuals Receiving Services/Residents, and Resident #1 Behavioral Intervention Protocol. No employee was allowed to work until there was in-service.
- CNA #1 and LPN #1 were placed on administrative leave pending completion of the investigation.
- LPN #1 was terminated from employment for observing physical abuse and failing to report it in a timely manner.
- CNA #1 was terminated from employment for physically abusing Resident #1.
- The Investigator notified the State Agency by telephone, and the Attorney General's Office in writing of the incident.
- Supervisors began in-servicing all employees prior to the beginning of their shift. The in-services were completed.
Failure to Prevent and Report Physical Abuse of a Resident
Penalty
Summary
The facility failed to implement its abuse prevention policy, resulting in a physically abusive incident involving a resident. On the specified date, a Certified Nurse Assistant (CNA) dragged a resident by the neck and shoulders of his clothing up the hallway and into his room. This action was witnessed by a Licensed Practical Nurse (LPN) and other staff members, none of whom intervened to stop the abuse or immediately report the incident as required by facility policy. The resident, who has a history of epilepsy, bipolar disorder, mild intellectual disabilities, and severely impaired vision, was observed lying on the floor, hitting his head, and refusing to wear his protective helmet prior to the incident. Multiple staff members, including another CNA and a housekeeper, witnessed the event but did not intervene or promptly report it. The LPN present at the scene acknowledged in a written statement that she felt the resident was being abused but only reported the incident to a security officer in a general manner and did not notify the Director of Nursing (DON) immediately. The security officer confirmed he was approached with general questions about abuse but was not informed of the specific incident until days later. Video surveillance confirmed the CNA dragging the resident approximately 16 feet down the hallway, with the LPN walking beside them. The resident later confirmed being dragged and expressed embarrassment over the incident. Staff interviews revealed a lack of immediate intervention and reporting, with some staff assuming others would handle the situation. The facility's policy required all employees to immediately report any suspicion or witness of abuse, but this was not followed. The failure to intervene and report placed the resident and others at risk of serious harm, and the incident was determined to be Immediate Jeopardy and Substandard Quality of Care.
Removal Plan
- The Quality Assurance Committee held an Emergency QA Meeting to discuss the incident and approve training.
- Training was provided at the beginning of the shift to all staff on Resident Rights, Suspicion of Abuse, Neglect, Exploitation, Injuries of Unknown Origin, and misappropriation of funds/Property to Individuals Receiving Services/Residents and Resident #1 behavior Intervention protocol.
- Abuse/Neglect Policy & Adherence to Care Plan will be monitored daily by using a minimum of 5 staff interviews per day, 5 days a week for 8 weeks by Nurse Manager and four Nurse Supervisors.
- Interventions and interactions with patients will be observed 5 days a week for 8 weeks by Nurse Manager and four Nurse Supervisors.
- Findings will be reported to QAPI (Quality Assurance Performance Improvement) for two months.
- All supervisors began training all oncoming staff before the start of their shift on Resident Rights, Suspicion of Abuse, Neglect, Exploitation, Injuries of Unknown Origin, or Misappropriation of Funds/Property to Individuals Receiving Services/Residents, and Resident #1 Behavioral Intervention Protocol. No employee was allowed to work until there was in-service.
- CNAs #1 and LPN #1 were placed on administrative leave pending completion of the investigation.
- LPN #1 was terminated from employment for observing physical abuse and failing to report it in a timely manner.
- CNA #1 was terminated from employment for physically abusing Resident #1.
- The Investigator notified the State Agency by telephone and the Attorney General's Office in writing of the incident.
- Supervisors began in-servicing all employees prior to the beginning of their shift. The in-services were completed.
Failure to Timely Report Physical Abuse Incident
Penalty
Summary
The facility failed to report an incident of physical abuse in a timely manner involving a resident with epilepsy, bipolar disorder, and mild intellectual disabilities, who had a moderately impaired cognitive status. On the day of the incident, a CNA dragged the resident by the neck and clothing up the hallway into the resident's room after the resident was observed banging his head against the wall and lying on the floor. Multiple staff members, including a nurse, a housekeeper, and another CNA, witnessed the event but did not immediately report it to the Director of Nursing or other supervisory staff as required by facility policy. The nurse who witnessed the abuse attempted to notify the DON but was unable to locate her and instead reported the incident to security. However, the incident was not formally reported to the DON or administrative staff until several days later, during the nurse's next scheduled shift. Other staff members who observed the event assumed that someone else would report it or did not intervene due to the brief duration of the incident. The CNA involved in the abuse did not self-report the incident. Facility policy required immediate reporting of any suspected abuse, but this was not followed. The delay in reporting resulted in the resident not being assessed until several days after the incident, and the abuse was not brought to the attention of the appropriate authorities or facility leadership in a timely manner. The failure to report placed the resident and others at risk, and the deficiency was determined to be Immediate Jeopardy and Substandard Quality of Care.
Removal Plan
- The Quality Assurance Committee held an Emergency QA Meeting to discuss the incident.
- The QA committee discussed and approved training provided at the beginning of the shift to all staff on Resident Rights, Suspicion of Abuse, Neglect, Exploitation, Injuries of Unknown Origin, and misappropriation of funds/Property to Individuals Receiving Services/Residents and Resident #1 behavior Intervention protocol.
- Abuse/Neglect Policy & Adherence to Care Plan will be monitored.
- Quality of corrections will be monitored daily by using a minimum of 5 staff interviews per day by Nurse Manager and four Nurse Supervisors.
- Quality of correction will also be monitored by observing interventions and interactions with patients by Nurse Manager and four Nurse Supervisors.
- Findings will be reported to QAPI.
- All supervisors began training all oncoming staff before the start of their shift on Resident Rights, Suspicion of Abuse, Neglect, Exploitation, Injuries of Unknown Origin, or Misappropriation of Funds/Property to Individuals Receiving Services/Residents, and Resident #1 Behavioral Intervention Protocol. No employee was allowed to work until there was in-service.
- CNAs #1 and LPN #1 were placed on administrative leave pending completion of the investigation.
- LPN #1 was terminated from employment for observing physical abuse and failing to report it in a timely manner.
- CNA #1 was terminated from employment for physically abusing Resident #1.
- The Investigator notified the State Agency by telephone and the Attorney General's Office in writing of the incident.
- Supervisors began in-servicing all employees prior to the beginning of their shift. The in-services were completed.
Failure to Implement Care Plan Interventions Results in Physical Abuse
Penalty
Summary
The facility failed to implement comprehensive care plan interventions for a resident with known behavioral issues, resulting in a serious incident of physical abuse. The resident, who had a history of self-injurious behavior such as hitting his head on floors and walls, was care planned to wear a helmet at all times when out of bed and to be redirected through engagement in activities or offering snacks and drinks. Despite these documented interventions, staff did not follow the care plan when the resident was found lying on the floor near the nurse's station, refusing to wear his helmet and exhibiting self-injurious behavior. On the day of the incident, a CNA who was not assigned to the resident responded by dragging the resident by the neck and shoulders of his jacket up the hallway into his room, rather than utilizing the care plan's redirection techniques. A nurse observed the abuse but failed to intervene or report the incident in a timely manner, allowing the situation to escalate. The care plan interventions, which were accessible to staff and reviewed periodically, were not implemented as required. The resident involved had diagnoses including epilepsy, bipolar disorder, and mild intellectual disabilities, with a moderately impaired cognitive status as indicated by a BIMS score of 12. The failure to follow the individualized care plan interventions placed the resident, and potentially all residents, at risk for serious harm. The deficiency was identified as Immediate Jeopardy due to the likelihood of causing serious injury, harm, impairment, or death.
Removal Plan
- The Quality Assurance Committee held an Emergency QA Meeting to discuss the incident.
- The QA committee discussed and approved training provided at the beginning of the shift to all staff on Resident Rights, Suspicion of Abuse, Neglect, Exploitation, Injuries of Unknown Origin, and misappropriation of funds/Property to Individuals Receiving Services/Residents and Resident #1 behavior Intervention protocol.
- Quality of corrections will be monitored by using a minimum of 5 staff interviews per day, 5 days a week for 8 weeks by Nurse Manager and four Nurse Supervisors.
- Quality of correction will also be monitored by observing interventions and interactions with patients 5 days a week for 8 weeks by Nurse Manager and four Nurse Supervisors.
- Findings will be reported to QAPI for two months.
- All supervisors began training all oncoming staff before the start of their shift on Resident Rights, Suspicion of Abuse, Neglect, Exploitation, Injuries of Unknown Origin, or Misappropriation of Funds/Property to Individuals Receiving Services/Residents, and Resident #1 Behavioral Intervention Protocol. No employee was allowed to work until there was in-service.
- CNAs #1 and LPN #1 were placed on administrative leave pending completion of the investigation.
- LPN #1 was terminated from employment for observing physical abuse and failing to report it in a timely manner.
- CNA #1 was terminated from employment for physically abusing Resident #1.
- The Investigator notified the State Agency by telephone, and the Attorney General's Office in writing of the incident.
- Supervisors began in-servicing all employees prior to the beginning of their shift. The in-services were completed.
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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