Tunica County Health & Rehab, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Tunica, Mississippi.
- Location
- 1024 Highway 61 South, Tunica, Mississippi 38676
- CMS Provider Number
- 255334
- Inspections on file
- 15
- Latest survey
- October 1, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Tunica County Health & Rehab, Llc during CMS and state inspections, most recent first.
Surveyors identified that two residents did not have comprehensive, person-centered care plans addressing their specific needs. One resident with limited range of motion and a history of cerebral infarction lacked a care plan for contracture risk or ROM exercises, while another resident with diabetes and self-care limitations had no care plan for fingernail care despite visible hygiene concerns. The MDS nurse confirmed these omissions.
A resident with a history of cerebral infarction developed a significant contracture in the left leg after not receiving documented range of motion (ROM) exercises or therapy. Staff interviews confirmed that neither therapy nor CNAs provided or documented ROM services, and there was no restorative program in place. Facility policy required assessment and management of functional impairment, but these procedures were not followed, leading to the resident's avoidable decline.
A resident with a history of cerebral infarction and limited range of motion experienced a 15-day delay in receiving a physical therapy evaluation after a referral was made for left leg stiffness. The delay occurred because a physical therapist was not available, and therapy assistants could not perform the initial evaluation, which did not meet the facility's policy for timely therapy services.
Dietary staff prepared and served food without hair restraints due to a lack of available hair nets, and multiple food items in both refrigerated and dry storage were found uncovered, undated, or not stored in sealed containers. Facility leadership confirmed these practices did not meet established food safety policies.
Leaking AC units in two resident rooms were not promptly reported or repaired, resulting in sheets and blankets being placed on the floor to absorb water. Staff confirmed the leaks and the delayed notification to maintenance, while the DON acknowledged that this practice compromised cleanliness and comfort for residents.
A resident with Alzheimer's disease was inaccurately coded on the MDS as using bed rails as restraints, despite facility documentation and staff interviews confirming that the side rails were used for mobility and bed boundary purposes and were not considered restraints.
A resident with diabetes who required moderate assistance with self-care was found to have long, dirty fingernails with a dark buildup, and reported not receiving nail care since admission. Staff and the DON confirmed the lack of nail care, which was not in accordance with facility policy requiring regular assessment and trimming, especially for diabetic residents.
A resident requiring a total mechanical lift for transfers was manually transferred by a CNA, resulting in a right tibia fracture. The CNA admitted to not following the care plan, which specified the use of a total lift with two staff members. The resident, who was cognitively intact and had conditions including epilepsy and dementia, sustained an acute fracture due to this deviation from the care plan.
A resident sustained a right tibia fracture due to an improper transfer by a CNA who failed to use the required total lift with two-person assistance. The resident's foot became entangled in the chair's footrest during the transfer, contrary to the care plan. The CNA admitted to the improper transfer, which was confirmed by the facility's investigation.
A resident with moderate cognitive impairment refused multiple doses of various medications over a two-week period. Despite the facility's policy requiring notification of the medical provider after two consecutive refusals, the medical provider was not informed. Interviews with the resident, DON, and an LPN confirmed the lack of notification, acknowledging the oversight and the potential risk it posed to the resident's health.
A facility failed to follow a fall risk care plan for a resident with a history of cerebral vascular accident and dementia, requiring two staff for mechanical lift transfers. An incident occurred when a CNA transferred the resident alone, leading to instability and the resident being assisted to the floor. Interviews confirmed the care plan was not followed, as the facility policy required two staff for such transfers.
A resident with dementia and cerebral infarction was transferred using a mechanical lift by a single CNA, contrary to the facility's policy requiring two staff members. During the transfer, the resident became unstable and was assisted to the floor, resulting in a minor injury. The CNA admitted to not following the policy due to the resident's condition at the end of her shift.
A facility failed to inform a contracted ESRD facility about a resident's repeated medication refusals. The resident, with ESRD and post-surgical care needs, refused multiple medications crucial for her health. Despite awareness of these refusals, staff did not communicate this to the dialysis clinic, potentially impacting the resident's treatment plan and health.
A resident's refrigerator was found to be unclean, with mildew present, indicating it had not been cleaned as per the facility's policy. The facility's policy required weekly cleaning of resident refrigerators, but there was no documentation to confirm this was done. The DON acknowledged the potential risk of foodborne illness due to the unclean refrigerator. The resident had a diagnosis of dementia.
Failure to Develop Comprehensive Care Plans for Identified Resident Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans to address the specific needs of two residents. For one resident with a history of cerebral infarction and a documented functional limitation in range of motion on one side, there was no care plan in place to address the risk for contracture or the need for range of motion (ROM) exercises, despite the resident being observed with her left leg bent and unable to straighten it. The resident also reported not receiving ROM exercises or splinting, and the MDS assessment confirmed the functional limitation. For another resident with Type 2 Diabetes Mellitus who required partial to moderate assistance with self-care, there was no care plan developed to address fingernail care, even though the resident was observed with excessively long fingernails and a dark brown substance under the nail beds. The MDS nurse confirmed that the care plans for both residents did not address these specific needs and acknowledged that these omissions should have been included to direct resident-specific care.
Failure to Provide Range of Motion Services Resulting in Contracture
Penalty
Summary
The facility failed to provide adequate services to prevent an avoidable decline and the development of a contracture in a resident with a history of cerebral infarction and limited range of motion (ROM). The resident was observed with her left leg bent at a 90-degree angle, unable to straighten it, and reported not receiving ROM exercises or splinting. Review of therapy records showed that no contracture was present at the time of admission, but a significant contracture developed over time, as documented in a later therapy evaluation. Progress notes indicated swelling and contraction of the left lower extremity, but there was no evidence of timely intervention or consistent ROM exercises being provided. Interviews with staff, including an LPN and the Rehabilitation Director, confirmed that the resident had not received therapy or documented ROM services, and that there was no restorative program in place. The Rehabilitation Director assumed that CNAs were providing ROM during care, but could not provide documentation to support this. The Administrator also confirmed the absence of documentation showing that ROM exercises were performed by either CNAs or therapy staff. Facility policy required assessment, recognition, and management of functional impairment, but these procedures were not followed, resulting in the resident's avoidable decline in mobility.
Delay in Therapy Evaluation for Resident with Contracture Risk
Penalty
Summary
The facility failed to ensure timely provision of specialized rehabilitative services for a resident with a history of cerebral infarction and functional limitation in range of motion. A request for physical and occupational therapy was made due to the resident's complaint of left leg stiffness, and at the time of referral, the resident's knee was slightly bent but not contracted. However, there was a 15-day delay between the therapy referral and the physical therapy evaluation, as a physical therapist was not available and therapy assistants were not permitted to perform the initial evaluation. Interviews with facility staff confirmed that the delay did not meet the facility's expectation for therapy evaluations to be completed within 24 to 48 hours of referral. The Rehabilitation Director acknowledged that the delay in evaluation and treatment could have contributed to the worsening of the resident's contracture. Facility policy required therapy services to be scheduled in accordance with the resident's treatment plan, which was not followed in this instance.
Failure to Maintain Sanitary Food Preparation and Storage Practices
Penalty
Summary
Dietary staff were observed preparing and serving food without wearing hair restraints, as required by facility policy. During a kitchen tour, three dietary aides were seen working in the kitchen without hair nets, and one aide confirmed that the facility had run out of hair nets, resulting in breakfast being prepared and served without any staff wearing proper hair restraints. The Dietary Manager also confirmed the lack of available hair nets for staff use. Additionally, multiple food storage violations were identified. In the refrigerator, a tray of individual pineapple cups was found uncovered and undated. The walk-in cooler contained several food items, including sauces, dressings, cheeses, meats, and lettuce, all lacking dates indicating when they were opened or when they would expire. In the dry goods storage area, items such as corn meal, basil leaves, poultry seasoning, cake mix, and graham cracker crumbs were found without open dates and not stored in sealed containers. The Dietary Manager and Administrator both confirmed that these practices did not comply with facility policy and food safety guidelines.
Failure to Report and Repair Leaking AC Units Compromises Resident Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment by not repairing or reporting leaking air-conditioning (AC) units in two resident rooms. Observations revealed that sheets and blankets were placed on the floor under the AC units in both rooms to absorb leaking water. These conditions persisted over multiple days, as confirmed by follow-up observations. Staff interviews verified that the sheets and blankets were used because the AC units were leaking, but the issue was not reported to maintenance in a timely manner. The leaking AC unit in one room was not logged onto the Maintenance Requisition form until after the state agency had entered the facility. Further interviews with maintenance staff confirmed that they had not been notified of the leaking AC units prior to the survey, and they were unaware of how long the units had been leaking. The Director of Nursing acknowledged that the practice of placing sheets and blankets under the leaking AC units without notifying maintenance could result in an unsanitary environment and diminished comfort for residents. Facility policy required that residents be provided with a safe, clean, comfortable, and homelike environment, which was not upheld in this instance.
Inaccurate MDS Coding for Restraint Use
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for one resident, resulting in a discrepancy between the MDS and the resident's restraint assessment. Specifically, the quarterly MDS indicated that bed rails were used daily as restraints, while the restraint assessment form completed two days prior documented that no restraints were in use. Staff interviews confirmed that the resident used bilateral side rails to aid in mobility and define bed boundaries, and these were not considered restraints according to facility policy. The MDS nurse acknowledged the inaccurate coding and confirmed that the resident had been assessed for side rail use, but the side rails were not classified as restraints. The resident involved had a diagnosis of Alzheimer's disease and had been admitted to the facility with this condition.
Failure to Provide Fingernail Care for Dependent Resident
Penalty
Summary
The facility failed to provide necessary fingernail care for a resident who was unable to perform this activity independently. Observations revealed that the resident's fingernails were long, approximately 1/2 inch past the fingertips, and had a thick, dark brown substance under the nail beds. The resident reported feeling that his nails were too long and dirty and stated he had not received any nail care since his admission. Staff interviews confirmed the condition of the resident's nails and acknowledged that they required attention. The resident in question was admitted with a diagnosis of Type 2 Diabetes Mellitus and required partial/moderate assistance with self-care, as indicated by the admission MDS. Facility policy required regular assessment and care of fingernails, especially for diabetic residents, to prevent infection. The DON confirmed that the resident's nails should have been assessed at least every two weeks by an RN and trimmed as needed, but this was not done, resulting in the observed deficiency.
Failure to Follow Care Plan Results in Resident Injury
Penalty
Summary
The facility failed to implement a person-centered care plan for a resident who required a total mechanical lift for all transfers. On a specific date, a Certified Nursing Assistant (CNA) manually transferred the resident using a stand-pivot method instead of the prescribed total lift with two staff members. This action resulted in the resident sustaining a right tibia fracture. The CNA admitted to knowing the resident's care plan required the use of a total lift but did not follow it, leading to the resident's injury. The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13, had been admitted to the facility with diagnoses including epilepsy, polyneuropathy, and dementia. Following the improper transfer, the resident experienced pain and swelling in the right knee and was later diagnosed with an acute, impacted fracture of the proximal tibia. The incident highlights a failure to adhere to the care plan, which was designed to meet the resident's physical needs and prevent injury.
Improper Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to ensure a resident was free from accident hazards when a Certified Nurse Assistant (CNA) transferred a resident from a geri-chair to her bed incorrectly, resulting in a right tibia fracture. The incident occurred when the CNA used a stand-pivot transfer instead of the required total lift with two-person assistance, as outlined in the resident's care plan. The resident's foot became entangled in the footrest of the reclined chair during the transfer, leading to the injury. The resident, who had been admitted with diagnoses including epilepsy, polyneuropathy, and dementia, initially complained of right knee pain without any visible swelling or redness. The pain was initially attributed to increased activity during the day. However, the following day, the resident's knee was noted to be swollen and painful, prompting further evaluation and notification of the Director of Nurses (DON) and the physician. A CT scan later confirmed a right tibial fracture. Interviews with staff revealed that the CNA was aware of the resident's transfer requirements but chose to transfer the resident independently without the use of a mechanical lift. The CNA admitted to the improper transfer during a phone call with the Administrator and DON. The facility's investigation confirmed that the CNA's actions were inconsistent with the resident's care plan, leading to the injury.
Failure to Notify Medical Provider of Medication Refusal
Penalty
Summary
The facility failed to notify the medical provider of a change in a resident's status when a resident refused her medications two or more consecutive times. The policy titled 'Change in a Resident's Condition or Status' requires the nurse supervisor or charge nurse to notify the resident's attending physician when there has been a refusal of treatment or medications two or more consecutive times. However, the facility did not adhere to this policy for one of the seven residents reviewed for medication regimen. Resident #46 refused multiple doses of various medications, including Cosopt eye drops, Docusate Sodium, Pepcid, Aspirin, Plavix, Vitamin C, Zinc, a multivitamin with minerals, Rena Vite, Norvasc, Sodium Bicarb, Pro-stat, Arginaid, and Velphoro, over a period from June 4th to June 17th. Interviews with Resident #46, the Director of Nursing (DON), and an LPN confirmed the lack of notification to the medical provider about the resident's continued refusal of medications. Resident #46, who was moderately cognitively impaired, acknowledged not taking all her medications. The DON confirmed that the medical director should have been notified of the resident's continued refusal, as failure to do so put the resident at risk for decompensation, organ failure, or acute illness. The LPN admitted awareness of the medication refusals but did not notify the medical provider, acknowledging that she should have done so. The facility's failure to notify the medical provider of the resident's medication refusals constitutes a deficiency in care.
Failure to Implement Fall Risk Care Plan
Penalty
Summary
The facility failed to implement a fall risk care plan for a resident who required the assistance of two staff members during transfers using a mechanical lift. The care plan for the resident, who was at risk for falls due to a cerebral vascular accident with left hemiparesis and muscle weakness, specified that two staff members were needed for transfers. However, an incident occurred where a Certified Nurse's Assistant (CNA) attempted to transfer the resident with only one staff member, resulting in the resident becoming unstable and being assisted to the floor to prevent a fall. Interviews with facility staff, including the Director of Nursing (DON) and a Minimum Data Set (MDS) nurse, confirmed that the facility's policy required two staff members for mechanical lift transfers unless otherwise specified in the care plan. The CNA involved in the incident admitted to not following the care plan by transferring the resident alone. The resident had been admitted to the facility with a diagnosis of unspecified dementia and cerebral infarction, which contributed to their increased fall risk.
Failure to Follow Mechanical Lift Policy Leads to Resident Incident
Penalty
Summary
The facility failed to implement necessary interventions to reduce the risk of accidents and hazards during the transfer of a resident using a mechanical lift. The policy titled 'Lifting Machine, Using a Portable,' revised in February 2014, mandates that two nursing assistants are required to perform the procedure. However, on 6/14/24, a Certified Nurse's Assistant (CNA) transferred a resident with only one staff assist, contrary to the policy. During the transfer, the resident became unstable due to being combative and was assisted to the floor to prevent a fall, resulting in a small, reddened area on the left knee. The resident was then lifted from the floor by four staff members and placed in a wheelchair. Interviews with staff, including CNA #3 and the Director of Nursing (DON), confirmed that the use of two staff members is required for mechanical lift transfers to minimize the risk of injury. CNA #2 admitted to transferring the resident alone, acknowledging the requirement for two staff but citing the resident's wet condition at the end of her shift as the reason for her action. The resident involved had been admitted to the facility with a diagnosis of Unspecified Dementia and Cerebral infarction, necessitating careful handling during transfers.
Failure to Communicate Medication Refusals to Dialysis Clinic
Penalty
Summary
The facility failed to communicate pertinent information regarding a resident's medication refusals to a contracted End-Stage Renal Disease (ESRD) facility. Resident #46, who has a diagnosis of ESRD and orthopedic aftercare following a surgical amputation, refused multiple doses of various medications and supplements over a period from June 4th to June 17th. These medications included treatments for glaucoma, constipation prevention, GERD, history of CVA, peripheral vascular disease, wound healing, and ESRD management. Despite these refusals, there was no documentation on the June Dialysis Transfer forms indicating that the dialysis clinic was informed of the resident's non-compliance with her medication regimen. Interviews with the resident, the Director of Nursing (DON), a Dialysis Registered Nurse (RN), and a Licensed Practical Nurse (LPN) revealed a lack of communication regarding the resident's medication refusals. The resident acknowledged not taking all her medications, while the DON confirmed the absence of communication to the dialysis clinic. The Dialysis RN was unaware of the refusals and emphasized the importance of this information for the resident's treatment plan. The LPN admitted awareness of the refusals but failed to communicate this to the dialysis clinic. This lack of communication potentially put the resident at risk for adverse health outcomes.
Failure to Maintain Cleanliness of Resident's Refrigerator
Penalty
Summary
The facility failed to maintain the cleanliness of a resident's personal refrigerator, which is a requirement for food safety. During an observation, it was found that a resident's refrigerator contained black spots identified as mildew, indicating it had not been cleaned as per the facility's policy. The policy stated that foods requiring refrigeration could be stored in a resident's personal refrigerator, and a designated employee was responsible for keeping it clean and free from spills. However, the refrigerator was found to be extremely dirty, with mildew present, and contained two fruit cups and four bottles of water. Interviews with the staff, including an LPN and the DON, revealed that the refrigerators were supposed to be cleaned weekly during the night shift, but there was no documentation log to confirm when the task was completed. The DON acknowledged that the unclean refrigerator could pose a risk of foodborne illness to the resident. The Infection Preventionist also confirmed that there was no system in place to verify the cleaning schedule, and it was unclear when the refrigerator was last cleaned. The resident involved had been admitted to the facility with a diagnosis of dementia.
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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