Tippah County Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Ripley, Mississippi.
- Location
- 1005 City Avenue North, Ripley, Mississippi 38663
- CMS Provider Number
- 255130
- Inspections on file
- 18
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Tippah County Nursing Home during CMS and state inspections, most recent first.
Dietary Manager Not Qualified by CDM Certification: The facility failed to ensure the Dietary Manager obtained or enrolled in a CDM program. Staff could not provide a policy on dietary staff qualifications, the Dietary Manager stated he had not completed a CDM program and was unaware it was required, and personnel records showed he had been hired about two years earlier without completing or enrolling in certification. The Administrator stated she was unaware the Dietary Manager was required to have CDM certification.
Failure to Follow Infection Control Practices During Wound and Catheter Care: An LPN did not perform hand hygiene after removing a soiled dressing and before donning clean gloves during wound care for a resident with a Stage 2 pressure injury and moderate cognitive impairment. In a separate observation, a CNA did not use EBP, including wearing a gown, during catheter care for another resident with an indwelling Foley catheter and moderate cognitive impairment. The DON confirmed EBP should have been used during catheter care and hand hygiene should have been performed before donning gloves.
Failure to resolve a grievance about incontinence care during meals: a resident's caregiver reported the resident was left in a soiled brief for hours while staff said briefs were not to be changed during meal times and tray passes. Resident Council minutes showed admin instructed staff not to provide incontinence care during mealtimes, and CNAs and an LPN confirmed this practice, despite the Administrator stating residents should be checked every 2 hours and changed as needed, including during meals. The resident had Cerebral Infarction and severely impaired cognition.
Broken Window Blinds in Resident Rooms: The facility failed to keep window coverings intact and in good repair in two resident rooms. Surveyors observed blinds with broken and missing slats, leaving a large gap at the bottom and exposing the outside elements. A CNA confirmed the issue had been reported, and the Administrator stated the blinds were unsightly and did not meet the facility's homelike environment expectation. The Maintenance Director said repairs depend on a work order and was only notified about one room.
Failure to implement individualized care plans for a resident with DM and ADL needs. The resident’s care plans included diabetic nail care and personal hygiene assistance with cueing and supervision, but staff observed long, jagged fingernails and long chin hairs that had not been addressed. An LPN confirmed the nail care and facial hair care were not completed as expected, and the MDS nurse confirmed the ADL and DM care plans were not implemented.
Failure to provide ADL hygiene care for a resident with DM and intact cognition. The resident was observed with long, jagged fingernails and long chin hairs, and stated both needed to be trimmed. An LPN confirmed the nails could cause a skin tear and said RN-only diabetic nail care was scheduled on the TAR, while the shower aide should have addressed the facial hair during the shower.
Medication labels did not match MAR orders for a resident during med pass. An LPN removed pharmacy-prepared blister packs labeled Gabapentin 300 mg and Propranolol HCl ER 80 mg from the locked narcotic box and administered two tablets/capsules of each because the MAR ordered Gabapentin 600 mg and Propranolol HCl ER 160 mg. The LPN said the discrepancy had been present since admission, and the DON and Administrator said staff had not reported it; the resident was cognitively intact with a BIMS score of 13.
The facility failed to maintain a safe and sanitary environment in two shower rooms, with significant damage to walls and ceilings, including missing plaster and exposed metal. The Administrator and DON acknowledged the potential for injury, and the Maintenance Director confirmed awareness of the issues but had not completed repairs.
A facility failed to develop a hospice care plan for a resident receiving hospice services, despite an order to admit the resident to hospice care. The MDS Coordinator and Administrator acknowledged the oversight, noting the resident had been on and off hospice care, which contributed to the lapse. The absence of a care plan was confirmed during a review of the resident's records.
A facility failed to properly store a nebulizer mask and tubing, leaving them exposed on a nightstand without protective covering, contrary to their policy. This was confirmed by an LPN and the Administrator, who acknowledged the potential for contamination and respiratory infections. The resident involved had a history of respiratory issues and was receiving albuterol treatments.
Dietary Manager Not Qualified by CDM Certification
Penalty
Summary
The facility failed to ensure that the Dietary Manager was qualified by obtaining or enrolling in a Certified Dietary Manager (CDM) program for 3 of 3 days of survey. Surveyors requested a facility policy related to dietary staff qualifications, but staff were unable to provide a policy outlining requirements for CDM certification. During an interview, the Dietary Manager stated that he had not completed a CDM program and was unaware that he was required to obtain certification. Review of personnel records showed that the Dietary Manager had been hired approximately two years earlier and had not completed or enrolled in a CDM program. During an interview, the Administrator stated she was unaware that the Dietary Manager was required to obtain CDM certification.
Failure to Follow Infection Control Practices During Wound and Catheter Care
Penalty
Summary
The facility failed to implement infection prevention and control practices during resident care observations. During wound care for Resident #3, an LPN removed the soiled dressing and then did not perform hand hygiene before putting on clean gloves. The LPN later stated she forgot to perform hand hygiene during the procedure and acknowledged that hand hygiene should be performed before donning gloves to help prevent the possible spread of infection. Resident #3 had a Stage 2 pressure injury to the coccyx and a BIMS score of 9, indicating moderate cognitive impairment. During catheter care for Resident #6, a CNA was observed not using Enhanced Barrier Precautions because she did not wear a gown during the procedure. The CNA stated she was aware EBP should have been used during catheter care but forgot, and confirmed that EBP are used to prevent the spread of infection between staff and residents and between residents. Resident #6 had an indwelling Foley catheter ordered for daily cleansing and a BIMS score of 8, indicating moderate cognitive impairment. The Administrator and DON confirmed that EBP should have been used during catheter care and that hand hygiene should be performed before donning gloves.
Failure to Resolve Grievance About Incontinence Care During Meals
Penalty
Summary
The facility failed to honor the resident's right to organize and participate in resident/family groups by not acting on and resolving a grievance related to incontinent care for Resident #27. The facility policy titled Activities of Daily Living (ADL) Care stated that ADL care is to be provided daily as needed, residents are to be checked every two hours on each shift, and adult briefs are to be changed if needed. However, the resident's caregiver reported that Resident #27 had been left in a soiled brief on more than one occasion while visiting daily, and said staff told her residents were not to be changed during meal times and meal tray passes. Resident Council meeting minutes showed administration instructed staff not to provide incontinence care during mealtimes. CNA #1, CNA #2, and LPN #1 confirmed that staff were expected to complete tray pass and feeding before providing incontinence care during meal service. The Administrator stated the expectation was for staff to provide incontinence care every two hours and as needed, including during mealtimes, and said residents should not remain in soiled briefs. Resident #27 had diagnoses including Cerebral Infarction and a BIMS score of 07, indicating severely impaired cognition.
Broken Window Blinds in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment by not ensuring window coverings were intact and in good repair in two resident rooms. During observation, the window blinds in rooms 230 and [ROOM NUMBER] were found to have broken and missing slats, leaving an approximate 30-inch gap at the bottom and exposing the outside elements. A CNA stated that when disrepair is noted in a resident room, nursing staff are notified so maintenance can be contacted, and she confirmed she had observed the broken blinds in [ROOM NUMBER] and reported the issue that morning. The Administrator confirmed the blinds in the affected rooms were broken, looked unsightly, and did not meet the facility's expectation of providing a homelike environment. The Maintenance Director stated maintenance needs are addressed when a work order is submitted and confirmed he had been notified that morning about replacing the blinds in [ROOM NUMBER], while also stating he had not been made aware of the need to inspect or repair the blinds in [ROOM NUMBER].
Failure to Implement Individualized Care Plans
Penalty
Summary
The facility failed to implement comprehensive care plans for one sampled resident with diabetes mellitus and ADL needs. The resident’s care plan for diabetes mellitus, initiated 8/26/2024, included diabetic nail care on Tuesdays, and the ADL care plan, also initiated 8/26/2024, stated the resident was able to perform personal hygiene care with cueing and supervision. However, during observation on 2/17/2026, the resident was found to have noticeably long, jagged fingernails measuring about one inch in length and several long facial hairs on the chin measuring about one and one-half inches in length. The resident stated the nails were too long and needed to be trimmed and that she did not want facial hair and would like it trimmed. During interview on 2/18/2026, an LPN confirmed the resident had long, jagged fingernails that could cause a skin tear and stated that because the resident has diabetes, an RN is required to trim the nails. The LPN also confirmed the resident had several long chin hairs and stated the shower aide should have taken care of this during the shower. On 2/19/2026, the MDS nurse confirmed the ADL and diabetes mellitus care plans were not implemented and stated the purpose of the care plans was to provide guidance for individualized care. The resident’s record showed diagnoses of encephalopathy, unspecified, and type 2 diabetes mellitus without complications, and the quarterly MDS indicated a BIMS score of 15, showing the resident was cognitively intact.
Failure to Provide ADL Hygiene Care
Penalty
Summary
The facility failed to provide ADL care to maintain personal hygiene for one resident with diabetes and cognitive intactness. During observation, the resident was noted to have noticeably long, jagged fingernails measuring about one inch in length and several long facial hairs on the chin measuring about one and one-half inches. The resident stated that the nails were too long and needed to be trimmed and that she did not want the facial hair and wanted it trimmed as well. An LPN confirmed the resident had long, jagged fingernails that could cause a skin tear and stated that because the resident has diabetes, only an RN could trim her nails. The LPN also confirmed the resident had several long chin hairs and stated the shower aide should have taken care of this during the shower. Record review showed diabetic nail care was scheduled on the TAR every Tuesday to be completed by the RN, and the Administrator stated the care should have been completed the previous day. The resident’s record showed diagnoses including Type 2 diabetes mellitus without complications, and the MDS indicated a BIMS score of 15.
Medication Labels Did Not Match MAR Orders
Penalty
Summary
The facility failed to ensure medications were accurately labeled and matched the physician’s orders for one resident observed during medication pass. During observation, an LPN retrieved pharmacy-prepared blister packs labeled Gabapentin 300 mg and Propranolol HCl ER 80 mg from the locked narcotic box and punched out two tablets/capsules of each medication, stating the MAR ordered Gabapentin 600 mg one tablet twice daily and Propranolol HCl ER 160 mg one capsule twice daily. Record review confirmed the MAR orders were for Gabapentin 600 mg and Propranolol HCl ER 160 mg, while the blister packs on hand were labeled for 300 mg Gabapentin with instructions for two tablets and 80 mg Propranolol with instructions for two capsules. The LPN stated the blister packs had been labeled that way since admission and that she had never thought to get them changed. The resident was admitted with diagnoses including unspecified muscle disorder, pain, and essential primary hypertension, and the MDS showed a BIMS score of 13, indicating the resident was cognitively intact. During interview, the Administrator and DON stated they were unaware of the discrepancy and acknowledged that nursing staff should have reported it so it could be corrected; the DON stated the mismatch could cause a medication error when the blister pack strength did not match the MAR.
Facility Fails to Maintain Safe and Sanitary Shower Rooms
Penalty
Summary
The facility failed to provide a safe, functional, and sanitary environment for residents, as evidenced by the disrepair of two shower rooms. Observations revealed significant damage to the walls and ceilings in both shower rooms, including missing plaster and exposed metal grill-like material. In the east hall shower room, a large open area of missing plaster was noted at the corner of the wall, and the ceiling around an air vent was damaged with hanging plaster and a black substance. Similarly, in the south hall shower room, the ceiling surrounding the air vent was damaged with open areas of plaster and a dark substance. Additionally, a large hole with missing plaster and exposed metal was observed behind the door where the doorknob met the wall. Interviews with the Administrator, DON, and Maintenance Director confirmed awareness of the damaged areas and the potential for injury due to the disrepair. The Administrator acknowledged that the entrance areas to the shower rooms had not been remodeled and that the maintenance department had been informed but had not completed the repairs. The Maintenance Director admitted difficulty in finding someone to perform the necessary repairs and provided measurements of the damaged areas, further confirming the need for repairs to ensure safety.
Failure to Develop Hospice Care Plan for Resident
Penalty
Summary
The facility failed to develop a care plan for hospice services for one of the residents, identified as Resident #15. According to the facility's policy on care plans, a comprehensive care plan must be developed for each resident, including measurable objectives and timetables to meet their medical, nursing, mental, and psychosocial needs. Despite an order dated May 9, 2024, to admit the resident to hospice care, the care plan for hospice services was not created. The Minimum Data Set (MDS) Coordinator confirmed that the resident was receiving hospice services and was assessed for hospice on the MDS assessment, but acknowledged that a care plan was not developed due to oversight. Interviews with the MDS Coordinator and the Administrator revealed that the resident had been on and off hospice care, which contributed to the oversight. The Administrator confirmed the necessity of a care plan for hospice services, acknowledging that it serves as a guide for staff in providing care. The absence of a hospice care plan for Resident #15 was confirmed during the review of the resident's records, which indicated that the resident was receiving hospice services as of the MDS assessment with an Assessment Reference Date of August 12, 2024.
Improper Storage of Nebulizer Supplies
Penalty
Summary
The facility failed to ensure the proper storage of a nebulizer facial mask and tubing for one of the residents, leading to a potential infection control issue. The facility's policy, revised on 03/13/18, requires that nebulizer supplies be placed in a plastic bag after each use. However, during an observation on 11/04/24, it was noted that the nebulizer machine, along with the facial mask and tubing, was left on the nightstand next to the resident's bed without any protective covering. Interviews with an LPN and the Administrator confirmed that the nebulizer mask and tubing were not stored in a protective bag, which could lead to contamination and respiratory infections. The resident involved had a history of shortness of breath, unspecified dementia, and chronic obstructive pulmonary disease, and was receiving albuterol treatments via nebulizer. The failure to adhere to the facility's infection control policy was observed and acknowledged by the staff, highlighting a deficiency in maintaining proper infection prevention measures.
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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