Tupelo Community Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Tupelo, Mississippi.
- Location
- 1901 Briar Ridge Road, Tupelo, Mississippi 38804
- CMS Provider Number
- 255136
- Inspections on file
- 25
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Tupelo Community Care Center during CMS and state inspections, most recent first.
A resident in a rehabilitation unit was verbally abused by an LPN for reporting delayed pain medication administration. The resident, cognitively intact and admitted for a tibia fracture, was confronted harshly by the LPN, causing emotional distress. Witnesses, including therapy staff, confirmed the LPN's demeaning behavior, and trauma assessments documented the resident's emotional harm.
The facility failed to provide dementia care training to staff before they began caring for residents with dementia. Interviews revealed that CNAs had not received such training, and the Staff Development Nurse confirmed it was not part of the new hire orientation. The facility's records showed no policy or inclusion of dementia care in the New Hire Program, despite having residents diagnosed with Dementia and/or Alzheimer's Disease.
The facility did not ensure that handrails in resident hallways were securely affixed, affecting all four hallways. Observations showed multiple loose handrails, and the Administrator confirmed they had been loose for some time, acknowledging a potential safety issue. The handrails were made of PVC pipes, and while replacement was considered, floor replacement was prioritized. Communication about fixing the handrails was noted from May, but corporate approval was pending. The facility lacked a policy on repairs.
The facility failed to provide dementia care training to new hire staff before they began caring for residents with dementia. Interviews revealed that CNAs had been working for months without such training, and the Staff Development Nurse confirmed that dementia care was not part of the new hire orientation. The Administrator acknowledged the need for this training, given the number of residents with dementia in the facility.
The facility was found deficient in managing resources and providing adequate care. Issues included broken equipment, lack of dementia care training, and inadequate hygiene care for residents. Several residents did not receive proper baths, nail trimming, or shaving. Equipment maintenance was poor, with loose handrails and damaged wheelchairs posing safety risks. The administration failed to address these issues effectively, with inadequate communication and follow-up from staff.
The facility's QAPI/QAA committee failed to maintain and monitor interventions, resulting in repeated deficiencies in ADL care, psychotropic medication monitoring, and infection control. Despite efforts to implement a Performance Improvement Plan, issues persisted due to ineffective communication, lack of accountability, and oversight within the facility.
The facility failed to monitor side effects of psychotropic medications for three residents, despite policy requirements. Residents with major depressive disorder, generalized anxiety disorder, and dementia were prescribed multiple psychotropic drugs without documented side effect monitoring. Interviews with staff confirmed the absence of routine monitoring, highlighting a significant oversight in resident care.
A resident returned from the hospital with a C-Diff infection and was not placed on contact isolation precautions, despite having a physician's order for treatment. Observations showed no isolation measures in place, and interviews with staff confirmed the oversight. The DON and Infection Control nurse acknowledged the resident should have been isolated to prevent infection spread.
The facility failed to implement care plans for personal hygiene and incontinence care for several residents, leading to unmet needs. A resident with mild cognitive impairment did not receive shaving assistance, while another with moderate impairment had untrimmed, dirty nails. Cognitively intact residents reported not receiving regular baths or timely incontinence care, with observations confirming these deficiencies. Staff acknowledged the care plans were not followed.
The facility failed to provide adequate ADL assistance and incontinent care for several residents. A resident with mild cognitive impairment did not receive requested facial hair removal, while another with moderate impairment had untrimmed, dirty nails. A double amputee resident reported irregular bathing, confirmed by staff and documentation. Incontinent care was insufficient for three residents, with reports of being left in soiled conditions and delays in care. The DON acknowledged these failures, highlighting a lack of consistent care and communication within the facility.
The facility failed to provide adequate care for several residents, resulting in unmet personal hygiene needs and neglect. A resident's request for facial hair removal was ignored, while another did not receive a bath for several days. A resident was left in soiled conditions due to ignored call lights, and another had long, dirty fingernails. Staff interviews revealed chronic understaffing, with aides overwhelmed by numerous responsibilities, leading to inadequate care.
A resident in a LTC facility was unable to receive coffee for a month due to a broken coffee machine, impacting her right to self-determination and choice. The issue was raised in a Resident Council meeting, and staff interviews revealed that a temporary method of making coffee caused delays. The resident, who was cognitively intact, expressed that coffee was a significant social activity, and the lack of it affected her and other residents.
A facility failed to provide timely written notification of a hospital transfer for a resident, as required by their policy. The resident, who was cognitively intact, was transferred due to chest pains, but the Discharge/Transfer notice lacked a signature and proof of mailing to the resident's representative. The representative confirmed not receiving any notification.
A facility failed to provide a resident and their representative with written notice of the bed-hold policy during a hospital transfer. The resident, who was cognitively intact, was unaware of the policy, and the representative confirmed not receiving any notice. The Business Office Manager could not prove that the notice was mailed, despite the facility's policy requiring such notification.
A resident was inaccurately coded in the MDS as receiving insulin injections, despite not being diabetic and having no record of insulin administration. The MDS Nurse confirmed the error, and the facility's policy requires accurate assessments to reflect residents' conditions.
A resident's wheelchair was found to have exposed foam on both armrests due to cracked protective covering, which had been in this condition for some time. The resident, who was cognitively intact, reported the roughness of the exposed areas. The DON confirmed the need for replacement to prevent skin injury and acknowledged the oversight in the repair system. The resident had diagnoses of muscle wasting, atrophy, muscle weakness, and cerebral infarction.
A facility failed to maintain a clean environment in a resident's room, where a fall protection floor mat was found covered in stains. Despite daily cleaning protocols, the mat remained unclean, and the facility lacked a specific policy for cleaning such mats. Staff interviews confirmed the necessity of daily cleaning to prevent infection spread.
Resident Verbal Abuse by LPN
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a staff member, specifically an LPN, who confronted the resident for reporting not receiving pain medications in a timely manner. The resident, who was cognitively intact with a BIMS score of 15, was admitted for short-term rehabilitation following a tibia fracture. The incident involved the LPN speaking harshly and in a demeaning tone to the resident, which was witnessed by other staff members, including a Speech Therapist and a Physical Therapy Assistant. These staff members provided written statements corroborating the resident's account of the LPN's confrontational behavior. The resident reported feeling emotionally unsafe and was visibly upset, crying after the encounter with the LPN. The resident had a history of requesting pain medications prior to therapy sessions, which were not administered in a timely manner, leading to the confrontation. The resident expressed that the LPN's behavior was the worst she had experienced, despite her background as a former City Police Officer. The resident's emotional distress was further documented in trauma assessments conducted by a Licensed Social Worker, which confirmed the resident's trauma following the incident. Interviews with other staff members, including CNAs and the Director of Rehabilitation, supported the resident's claims of the LPN's inappropriate conduct. The facility's investigation concluded that while abuse was not substantiated, the LPN exhibited poor customer service. However, the evidence from staff interviews and written statements indicated that the LPN's actions were perceived as abusive by the resident and other staff members, highlighting a failure to ensure the resident's right to be free from abuse.
Lack of Dementia Care Training for Staff
Penalty
Summary
The facility failed to ensure that staff were trained on dementia care before caring for residents with dementia. This deficiency was identified during a survey, where it was found that the facility did not have a policy on training staff or assessing their competency in dementia care. Interviews with Certified Nurse Assistants (CNAs) revealed that they had not received any training on dementia care, despite working at the facility for about four months. The Staff Development Nurse confirmed that dementia care training was not part of the new hire orientation, and the Administrator acknowledged that staff should receive such training due to the number of residents with dementia. The facility's records showed that the last dementia care in-services were conducted in August and October of the previous year, and the New Hire Program did not include dementia care training. The Facility Assessment Tool also did not list dementia care as a required topic for new hires. The Resident Matrix indicated that there were 16 residents with a diagnosis of Dementia and/or Alzheimer's Disease, with two residing on the B Hall. This lack of training and policy implementation led to a deficiency in the care provided to residents with dementia.
Loose Handrails in Resident Hallways
Penalty
Summary
The facility failed to ensure that handrails in the resident hallways were permanently affixed to the walls, affecting all four hallways. Observations on September 9, 2024, revealed multiple loose handrails with their ends not securely attached to the walls. During an interview, the Administrator confirmed that the handrails had been loose for some time and acknowledged that they could pose a safety issue for residents. The Administrator mentioned that the handrails were made of PVC pipes and that they had been considering replacing them, but prioritized floor replacement first. Communication from a company regarding options for fixing the handrails was noted from May 10, 2024, but approval from corporate had not yet been obtained. The facility also lacked a policy on facility repairs, as indicated by a statement from the Executive Director dated September 11, 2024.
Lack of Dementia Care Training for New Hires
Penalty
Summary
The facility failed to ensure that new hire staff were trained on dementia care before caring for residents with dementia. This deficiency was identified during a survey where it was found that the facility did not have a policy on training staff or assessing their competency in dementia care. Interviews with two Certified Nurse Assistants (CNAs) revealed that they had been working at the facility for about four months without receiving any training on dementia care. One CNA mentioned that she was unaware of any special considerations for dealing with residents with dementia, although she did not have any residents with such a diagnosis in her assigned area. Further interviews with the Staff Development Nurse and the Administrator confirmed that dementia care training was not part of the new hire orientation. The Staff Development Nurse, who had been in her role for about five years, acknowledged that dementia care training had never been included in the orientation process. The Administrator also confirmed that staff should receive dementia care training due to the significant number of residents with dementia in the facility. A review of the New Hire Program and the Facility Assessment Tool corroborated the absence of dementia care as a required training topic, despite the presence of 16 residents diagnosed with dementia or Alzheimer's Disease in the facility.
Deficiencies in Resident Care and Facility Management
Penalty
Summary
The facility was found to be deficient in several areas during a survey conducted over three days. The administration failed to manage resources effectively, as evidenced by the lack of a policy on administration or administrative staff, and the absence of dementia care training in new hire orientation. The facility's Executive Director and Director of Nursing (DON) were unaware of several ongoing issues, including broken equipment and inadequate care for residents, which were not addressed in a timely manner. For instance, the coffee maker used for residents had been broken for about two months, causing delays in service, and the facility's handrails had been loose for a while, posing a safety risk. The survey revealed multiple instances of inadequate care for residents. Several residents did not receive proper hygiene care, such as regular baths, nail trimming, and shaving, which are essential for their well-being. Resident #43 did not receive assistance with shaving, and Resident #59 complained about not having a bath since the previous Tuesday. Additionally, Resident #68 experienced delays in receiving incontinent care, and Resident #352 was often found soiled during therapy sessions, indicating a lack of timely care by the staff. The DON admitted that aides were expected to make rounds every two hours, but this was not consistently happening. The facility also failed to maintain equipment and the environment in a safe and sanitary condition. Resident #84's wheelchair arms needed replacement to prevent skin injury, and the facility's handrails were loose, which could lead to accidents. The DON and Administrator acknowledged these issues but had not implemented effective measures to address them. The lack of communication and follow-up was evident, as the DON relied on charge nurses and unit managers to ensure tasks were completed, but this oversight was insufficient. The facility's performance improvement plan did not address the root causes of these deficiencies, leading to ongoing issues with resident care and safety.
Repeated Deficiencies in ADL Care and Monitoring
Penalty
Summary
The facility's Quality Assessment Performance Improvement (QAPI)/Quality Assessment and Assurance (QAA) committee failed to maintain and monitor the interventions they had implemented, leading to repeated deficiencies in several areas. These deficiencies were initially cited during a recertification survey on May 18, 2023, and were found again during a subsequent survey on September 9, 2024. The repeated deficiencies included failure to implement an Activities of Daily Living (ADL) care plan, assist residents with ADLs, monitor for side effects of psychotropic medications, and place an infectious resident in contact isolation. The facility's inability to sustain an effective Quality Assurance Program was evident as these issues persisted across multiple surveys. Interviews with the Director of Nurses (DON) and the Administrator revealed a lack of effective communication and follow-up within the facility. The DON admitted to relying on charge nurses and Unit Managers to ensure tasks were completed, but acknowledged that this did not always happen. The Administrator confirmed that staffing concerns, ADL care, or care plans were not addressed during QAPI/QAA meetings. Despite efforts to implement a Performance Improvement Plan (PIP) and assign administrative nurses and Unit Managers to monitor resident care, no significant issues were identified or addressed. Both the DON and Administrator recognized a lack of accountability and oversight, contributing to the ongoing deficiencies.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to ensure residents were free from unnecessary drug use by not monitoring for side effects of psychotropic medications for three residents. The facility's policy required routine review and monitoring for side effects of these medications, but this was not adhered to. Resident #44, who was admitted with major depressive disorder and generalized anxiety disorder, was prescribed multiple psychotropic medications, including Duloxetine, Quetiapine Fumarate, Lorazepam, and Divalproex Sodium. Despite these prescriptions, there was no evidence of side effect monitoring. Similarly, Resident #54, with severe cognitive impairment and diagnoses including dementia with psychotic disturbance and major depressive disorder, was on a regimen of psychotropic medications such as Quetiapine Fumarate, Memantine, and others, yet lacked documented side effect monitoring. Resident #87, admitted with generalized anxiety disorder and major depressive disorder, was also prescribed several psychotropic medications, including Buspirone, Fluoxetine, and Trazodone, without any monitoring for side effects. Interviews with facility staff, including a registered nurse and the Director of Nursing, confirmed the absence of routine monitoring for side effects. The Pharmacy Consultant emphasized the importance of monitoring for adverse reactions, such as over-sedation, to determine if medication adjustments were necessary. This lack of monitoring represents a significant oversight in the care of residents receiving psychotropic medications.
Failure to Implement Contact Precautions for C-Diff Infection
Penalty
Summary
The facility failed to implement appropriate infection prevention and control measures for a resident who returned from the hospital with a Clostridium Difficile Colitis (C-Diff) infection. Despite having a physician's order for Fidaxomicin to treat C-Diff, the resident was not placed on contact isolation precautions upon their return. Observations revealed the absence of isolation barrels and signage indicating contact precautions in the resident's room. Interviews with the resident and staff confirmed the oversight, with the Licensed Practical Nurse (LPN) acknowledging that the resident was not on contact precautions and should have been. The Director of Nursing and the Assistant Director of Nursing/Infection Control nurse both confirmed that the resident should have been placed on contact isolation to prevent the spread of infection. The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, had been admitted to the facility with a diagnosis of Chronic Obstructive Pulmonary Disease and had a history of long-term antibiotic use. The failure to implement contact precautions was a clear deviation from the facility's policy and the Centers for Disease Control (CDC) guidelines for managing C-Diff infections.
Failure to Implement Care Plans for Personal Hygiene and Incontinence Care
Penalty
Summary
The facility failed to implement developed care plans for several residents, leading to unmet personal care needs. Resident #43, who has a mild cognitive impairment, expressed a preference for facial hair removal by shaving, which was not provided despite being part of her care plan. The Director of Nursing and the MDS Assistant confirmed that the care plan, which included shaving as part of the bathing routine, was not followed. Resident #151, with moderate cognitive impairment, had a care plan for nail care that was not implemented. The resident's fingernails were observed to be long and dirty, and she expressed a desire for them to be trimmed. The Director of Nursing confirmed the care plan for nail care was not followed, and the MDS Assistant acknowledged the failure to implement the care plan. Residents #59, #68, #351, and #352 experienced deficiencies in bathing and incontinent care. Resident #59, who is cognitively intact, reported not receiving regular baths as per his care plan. Resident #68, also cognitively intact, was left in wet clothing for an extended period, and Resident #351 was observed in urine-soaked clothing. Resident #352, who is cognitively intact, reported delays in receiving incontinence care, corroborated by a Physical Therapy Assistant who noted consistent issues with the resident being soiled during therapy sessions. The MDS Nurse confirmed that the care plans for these residents were not followed.
Deficiencies in ADL Assistance and Incontinent Care
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADLs) for several residents who were dependent on staff. Resident #43, who had a mild cognitive impairment, expressed a preference for facial hair removal, which was not fulfilled by the staff despite her requests. Observations confirmed the presence of facial hair, and the Director of Nursing (DON) acknowledged the failure to provide the necessary grooming care. Similarly, Resident #151, with moderate cognitive impairment, had long, dirty fingernails, and despite expressing a desire for nail care, the facility did not address this need. Resident #59, a double above-knee amputee, reported not receiving regular baths, stating he had not been bathed since the previous Tuesday. The resident required assistance with bathing, and documentation confirmed missed bathing schedules. Staff interviews revealed that the resident only received baths when a specific CNA was on duty, and complaints made to an LPN were not escalated or addressed. This lack of consistent bathing care was acknowledged by the staff involved. Incontinent care was also inadequately provided for Residents #68, #351, and #352. Resident #68, who was cognitively intact, reported being left in soiled conditions over the weekend, with staff failing to return after turning off the call light. The DON confirmed the incidents and the failure to provide timely care. Resident #351 was observed in wet clothing, with family members reporting consistent issues with incontinence care. The DON was unaware of these concerns until recently. Resident #352 experienced delays in being changed, with therapy staff noting the issue during sessions. The DON was not informed of these delays, indicating a communication breakdown within the facility.
Inadequate Staffing Leads to Neglect in Resident Care
Penalty
Summary
The facility failed to provide adequate nursing care for six out of seven residents reviewed for Activities of Daily Living (ADL) during the survey. Resident #43 expressed a preference for facial hair removal, which was not attended to by the staff despite multiple requests. Similarly, Resident #59, a double above-knee amputee, reported not receiving a bath since the previous Tuesday, and this was confirmed by the Certified Nurse Assistant (CNA) assigned to him. The documentation corroborated that the resident did not receive a bath on the specified date, highlighting a lapse in personal hygiene care. Resident #68 experienced neglect over a weekend when her call light was ignored, leaving her in soiled conditions for an extended period. The Director of Nursing (DON) acknowledged awareness of the incidents and took disciplinary actions against the aides involved. However, the resident reported that the aides did not check on her every two hours as expected. Resident #151 also suffered from neglect, with long fingernails and a brown substance under them, which the DON confirmed should have been addressed to prevent infections. Additional issues were observed with Resident #351, who was found in a urine-soaked state after returning from therapy, and Resident #352, who experienced delays in being changed after meals, affecting his therapy sessions. Interviews with staff revealed chronic understaffing, with aides responsible for numerous tasks and residents, leading to inadequate care. The facility's staffing policy based on resident acuity was insufficient to meet the needs of the residents, as evidenced by the numerous complaints and observations of neglect.
Resident's Right to Coffee Denied Due to Broken Machine
Penalty
Summary
The facility failed to ensure a resident received coffee as desired, which is a violation of the resident's right to self-determination and choice. The deficiency was identified through observation, resident and staff interviews, and record reviews. A resident expressed that she had not received coffee for the past month due to a broken coffee machine in the kitchen. This issue was also raised during a Resident Council meeting, where residents were informed that the coffee machine was being repaired. The resident emphasized that coffee was a significant social activity for her and other residents, and the lack of it had negatively impacted their experience. Interviews with the Dietary Manager and the Administrator revealed that the coffee machine had been broken for about two months, and a temporary method of boiling water and using a filter was implemented, which caused delays in serving coffee to residents. The Dietary Manager acknowledged the residents' complaints and frustration, and the Administrator confirmed awareness of the issue but underestimated the duration of the problem. The Administrator also mentioned that a backup method was in place but was unaware of the delays it caused. The resident involved was cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 15.
Failure to Notify Resident and Representative of Hospital Transfer
Penalty
Summary
The facility failed to provide timely written notification of a discharge/transfer to the hospital for Resident #45, as required by their policy. The policy, titled 'Emergency Transfers Procedures,' mandates that an Emergency Transfer notice, including the date, reason for transfer, location, and contact information for State Agencies to initiate the appeal process, should be provided to the resident or their representative as soon as practicable. However, during a review, it was found that the Discharge/Transfer notice for Resident #45 was dated a day after the transfer and lacked a signature from either the resident or their representative. Interviews and record reviews revealed that the Business Office Manager admitted to mailing the forms to the responsible party but had no proof of mailing. The resident's representative confirmed not receiving any notification regarding the discharge/transfer. Resident #45, who was cognitively intact with a BIMS score of 15, was transferred to the emergency department due to chest pains. The facility admitted Resident #45 in December 2022 with a diagnosis related to urinary tract care, and the failure to notify the resident or their representative in writing of the hospital transfer was identified as a deficiency.
Failure to Provide Bed-Hold Notice
Penalty
Summary
The facility failed to provide written notice of the bed-hold policy to a resident and their representative during a transfer to a hospital. This deficiency was identified for one of three residents reviewed for bed holds. The facility's policy, titled F-625 Notice of Bed-Hold Policy, requires that at the time of a resident's transfer for hospitalization, the nursing facility must provide written notice of the bed-hold policy to both the resident and their representative. However, in the case of Resident #45, this procedure was not followed. Resident #45, who was admitted to the facility with a diagnosis related to urinary tract care, was transferred to the hospital without receiving the required bed-hold notice. During an interview, the resident stated she was unaware of the bed-hold policy. A review of the Bed-Hold Notice form for this resident showed a date of notice but lacked a signature from either the resident or their representative. The Business Office Manager admitted that the notices are mailed out but could not provide proof that the notice was sent. The resident's representative confirmed that they had never received any bed-hold notice, despite the resident having been hospitalized multiple times.
Inaccurate MDS Coding for Insulin Administration
Penalty
Summary
The facility failed to accurately complete section N of the 5-day Minimum Data Set (MDS) for one of the sampled residents. Specifically, Resident #22 was incorrectly coded as having received insulin injections for seven days during the 7-day look-back period since admission. However, upon review of the Medication Administration Record (MAR) for August 2024, it was found that Resident #22 did not receive insulin or any injections during this period. An interview with the resident confirmed that he was not diabetic and had never taken insulin injections. The MDS Nurse acknowledged the coding error, confirming that Resident #22 did not have a physician order for insulin. The facility's policy on MDS Assessment, revised in June 2023, mandates that assessments be conducted accurately to reflect the resident's condition and facilitate the development of an individualized care plan. The Administrator expressed that her expectation was for MDS assessments to be completed accurately. Resident #22 was admitted to the facility with a diagnosis of Chronic Obstructive Pulmonary Disease and had a Brief Interview for Mental Status (BIMS) score indicating moderate cognitive impairment.
Wheelchair Maintenance Deficiency
Penalty
Summary
The facility failed to ensure a wheelchair was in good, safe condition for one of the sampled residents. During an observation, it was noted that the wheelchair of Resident #84 had both armrests with foam exposed due to cracked protective covering. The left armrest was entirely affected, and the right armrest had a damaged area approximately four inches by one inch. Resident #84, who was cognitively intact with a BIMS score of 15, reported that the wheelchair had been in this condition for a while and that the exposed areas were rough to touch. The Director of Nursing confirmed that the wheelchair arms needed replacement to prevent potential skin injury and acknowledged that the issue was overlooked and not entered into their repair system. The resident had been admitted with diagnoses including muscle wasting, atrophy, muscle weakness, and cerebral infarction.
Failure to Maintain Clean Environment in Resident Room
Penalty
Summary
The facility failed to maintain a clean and homelike environment in one of the observed rooms, specifically room D5 B. During an observation, a fall protection floor mat was found to be covered in black and brown dried stains, and a clump of a brown leaf tobacco product was observed on the floor next to the mat. Although the tobacco product was cleaned up later, the floor mat remained stained. The facility lacked a policy on cleaning floor mats, as revealed by a document signed by the Executive Director. Interviews with staff, including a CNA, the DON, a housekeeper, and the Assistant Director of Nursing/Infection Control Nurse, confirmed that the floor mats should be cleaned daily to prevent infection spread. The CNA acknowledged the mat was filthy, and the DON emphasized the importance of daily cleaning. The housekeeper stated that resident rooms are cleaned daily, including mopping under mats and sanitizing the top of mats. The Assistant Director of Nursing/Infection Control Nurse reiterated the need for daily cleaning and sanitization of the mats to reduce infection risk.
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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