Yazoo City Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Yazoo City, Mississippi.
- Location
- 925 Calhoun Avenue, Yazoo City, Mississippi 39194
- CMS Provider Number
- 255146
- Inspections on file
- 26
- Latest survey
- April 10, 2026
- Citations (last 12 mo.)
- 8 (1 serious)
Citation history
Health deficiencies cited at Yazoo City Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with tracheostomy status, COPD, and acute/chronic respiratory failure, who required scheduled trach suctioning and nebulizer treatments, was discharged home without essential respiratory DME, specifically a suction machine and nebulizer. Although social services arranged some DME (hospital bed, wheelchair, bedside commode) and home health services, there was no evidence that suction or nebulizer equipment was ordered or delivery verified, despite facility policy requiring confirmation of all needed DME before discharge. After discharge, the resident lacked correct tracheostomy supplies at home, EMS was called to perform suctioning, and the resident was subsequently hospitalized. Interviews with the resident’s representative, social services, home health nurses, and the administrator confirmed that the suction machine was not included in the DME arrangements and that required equipment had not been ensured prior to discharge.
A resident with Type 2 DM and hyperglycemia had an active order for nightly Lantus insulin that was not administered over multiple days, and documentation showed the insulin was pending from pharmacy without further explanation for continued omissions. Despite a facility policy requiring MD notification when treatment needs to be significantly altered, there was no documentation that the MD or NP was informed that the ordered insulin was not given. The DON confirmed the lack of provider notification and acknowledged that this prevented the provider from assessing the resident and adjusting treatment as needed.
A resident with Type 2 DM with hyperglycemia had an active order for nightly Lantus insulin that was not administered for three consecutive days, despite facility policy requiring medications to be given as ordered. The MAR showed missed doses, while a progress note stated the insulin was "pending pharmacy" with no further explanation. Pharmacy delivery records confirmed the Lantus was delivered and signed for by two nurses, but an LPN later reported not recalling the resident or the medication. The DON verified that the insulin was not given, noted that the nurses who signed for the medication worked on a different unit and that it may not have been taken to the resident’s unit, and acknowledged that failure to administer the insulin as ordered could result in hyperglycemia.
A resident with paraplegia and a spinal cord injury, who was dependent on staff for toileting, did not receive incontinence care as outlined in the care plan. Observation revealed the resident's brief was saturated and unchanged overnight, and staff confirmed the care plan was not followed.
A resident who was dependent on staff for toileting due to paraplegia did not receive timely incontinent care, resulting in a saturated brief and incontinence pad. The resident reported not being checked or changed during the night, and staff confirmed that care had not been provided as required by facility policy.
A resident with hemiplegia, hemiparesis, hypertension, and blindness experienced multiple falls, but the care plan was not updated with new preventative interventions after each incident. The care plan only included post-fall actions such as neuro checks and notifications, without revising strategies to prevent further falls, as confirmed by the ADON.
A resident with hemiplegia, hemiparesis, hypertension, and blindness experienced five falls, including one resulting in a laceration and hematoma requiring emergency care. Despite facility policy requiring care plan updates after each fall, no new interventions were implemented following any of the incidents, and staff confirmed that the care plan was not revised to address the repeated falls.
A CNA misappropriated money from a resident with quadriplegia by accepting funds through Cash App and unauthorized use of the resident's trust fund card for personal purchases. The resident, who was cognitively intact, noticed unauthorized transactions and provided evidence linking the CNA to the misappropriation. Facility staff confirmed that only Social Services or Activities should assist with resident shopping, and the resident was unaware of this policy.
A resident with moderate cognitive impairment and high risk for wandering left the facility unnoticed due to a malfunctioning wander guard bracelet. Staff failed to monitor the resident adequately, as the resident was not checked on for several hours. The facility's policy on wander management was not effectively implemented.
A facility failed to implement care plans for a resident on Enhanced Barrier Precautions (EBP) and two residents requiring assistance with activities of daily living (ADL). An LPN did not follow EBP protocol during wound care, and two residents were found with neglected personal hygiene, including long, dirty nails and facial hair, despite care plans outlining necessary interventions. Staff confirmed the care plans were not followed.
Two residents in an LTC facility were not provided with necessary grooming and personal hygiene services. One resident, with moderate cognitive impairment, had long, jagged nails and facial hair despite expressing a desire for grooming. Another resident, cognitively intact but with quadriplegia, had excessively long, dirty fingernails and had repeatedly requested nail care. The DON acknowledged the facility's failure to meet these residents' grooming needs.
A resident's dignity was compromised when their urinary catheter bag was left uncovered, contrary to facility policy. The resident, who was cognitively intact and had a history of malignant neoplasm of the uterus and type 2 diabetes, expressed discomfort with the visibility of the urine. Staff interviews confirmed that the facility typically used privacy bags, but the resident's bag, likely from the hospital, was not covered, highlighting a lapse in maintaining resident dignity.
A facility failed to ensure a call light was accessible for a resident who relied on it for assistance. The resident, who was cognitively intact and had multiple health conditions, reported that the call light was not within reach. Observations confirmed the call light cord was tangled and inaccessible. Both a CNA and an RN acknowledged the issue, and the DON confirmed the facility's failure to secure the call light within the resident's reach.
A facility failed to resolve grievances related to missing clothing items for four residents, as identified during interviews and record reviews. Despite ongoing complaints documented in Resident Council meetings, the issue remained unresolved. Staff interviews confirmed awareness of the problem, with suggestions that laundry backlogs and unlabeled clothes contributed to the issue. The Administrator admitted awareness and efforts to address the problem, but it persisted. All involved residents were cognitively intact.
A facility failed to ensure a resident's code status was accurately reflected in the physician orders, leading to a discrepancy between the advance directive and the physician's order. The advance directive indicated a DNR preference, while the physician's order listed the resident as a full code. Staff interviews confirmed reliance on electronic medical records for code status, and the lack of a policy to address such discrepancies contributed to the issue.
The facility failed to maintain a clean and homelike environment, as evidenced by unsanitary conditions in multiple resident rooms. Observations included persistent odors, fecal matter on surfaces, improperly hung curtains, and black substances on air conditioning units. Housekeeping and CNA staff demonstrated a lack of clarity and training regarding cleaning responsibilities, contributing to these deficiencies. Additionally, a ceiling leak from an air conditioning unit was not addressed, further compromising the environment.
A resident receiving anticoagulant medication for Peripheral Vascular Disease was not monitored for signs of bruising and bleeding, as required by the facility's policy. Staff interviews confirmed the absence of a monitoring tool on the resident's MAR, despite the importance of such monitoring. The DON acknowledged the deficiency in monitoring the resident's condition.
A medication cart was left unlocked and unattended by an LPN during medication administration, contrary to facility policy. The cart was outside a resident's room for about 15 minutes, with residents nearby, creating a risk for unauthorized access. Staff interviews confirmed the cart should have been locked unless the nurse was present.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a wound and urinary catheter. An LPN performed wound care without donning a gown, contrary to the facility's EBP policy. The resident's care plan required EBP due to a deep tissue injury and indwelling device. The LPN admitted to forgetting the protocol, and an RN confirmed the oversight. The resident had a history of malignant neoplasm, pressure-induced injury, and diabetes, and was cognitively intact.
A high-risk resident with a history of wandering and delusional behavior managed to disassemble his bedroom window and leave the facility undetected. Despite being identified as high-risk and having a wander guard, the facility's measures were insufficient, leading to the resident being found several miles away by law enforcement approximately 5.5 hours later.
The facility failed to transport a dialysis resident to a scheduled surgical procedure to ligate an AV fistula, resulting in the resident being admitted to the hospital with a bleeding aneurysm and requiring a blood transfusion. The incident was identified as Immediate Jeopardy and Substandard Quality of Care by the State Agency due to the facility's neglect in ensuring the resident attended the critical appointment.
A facility failed to revise the care plan for a severely cognitively impaired resident, leading to the resident's unsupervised exit and subsequent elopement. Despite a BIMS score indicating severe cognitive impairment, the care plan was not updated to reflect the need for supervision during leave of absence (LOA). The resident was found by police approximately eight-tenths of a mile from the facility after being away for 81 minutes.
A severely cognitively impaired resident eloped from the facility and was found 0.8 miles away after being unsupervised for 81 minutes. The facility lacked effective communication and policies to prevent such incidents.
Failure to Ensure Required Respiratory DME Prior to Discharge
Penalty
Summary
The facility failed to implement an effective discharge planning process to ensure necessary durable medical equipment (DME) was arranged and received prior to discharge for one resident. The resident had diagnoses including acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, and tracheostomy status, and had physician orders for tracheostomy suctioning every four hours and as needed, and inhalation therapy via nebulizer every six hours. Facility protocol for a safe discharge process required that all necessary services, equipment, and supports, including DME, be ordered, coordinated, and verified as delivered and functional prior to discharge, with discharge not to occur until this was confirmed. Record review showed that social services arranged discharge with home health services and DME including a hospital bed, wheelchair, and bedside commode, but the record lacked evidence that a suction machine or nebulizer was arranged or verified prior to discharge. The resident was discharged home without a suction machine or nebulizer. Hospital medical records documented that the resident presented to the hospital via EMS because the correct supplies for tracheostomy care were not available at home, and the resident was admitted because it was unsafe to remain at home without the necessary equipment. Interviews further confirmed the failure in discharge planning. The resident’s representative reported that no nebulizer or suction equipment was received at discharge, EMS had to be called to suction the resident, and the resident was hospitalized until equipment was obtained. Social services initially stated she believed all equipment had been delivered and denied knowledge that suction or nebulizer equipment was not received, later acknowledging she did not arrange for a suction machine or nebulizer and did not verify delivery of all required equipment, believing home health would provide those items. A home health nurse reported that the facility notified the agency of tracheostomy supplies and nebulizer needs but did not include a suction machine and confirmed it was the facility’s responsibility to ensure DME was ordered and delivered prior to discharge. The administrator stated it was the expectation that all required equipment be in place prior to discharge and acknowledged that failure to provide necessary equipment could result in respiratory distress and/or death.
Failure to Notify Provider of Omitted Insulin Doses
Penalty
Summary
The facility failed to notify the physician or nurse practitioner of omitted insulin doses for one resident with Type 2 diabetes mellitus with hyperglycemia. Facility policy titled "Condition & Medical Doctor (MD)-Family Notification" required that the resident’s family and/or legal representative and physician be notified of resident changes that necessitate a significant alteration in treatment. The Order Summary Report for Resident #2 showed an active order for Lantus SoloStar insulin, 10 units subcutaneously at bedtime, starting on 1/16/26. Review of the January 2026 MAR revealed that the resident did not receive the ordered insulin doses on 1/16/26, 1/17/26, and 1/18/26. Progress notes dated 1/16/26 documented that the insulin was pending from the pharmacy, but there was no further explanation for the continued omission of the medication on subsequent days. Additional review of progress notes from 1/16/26 through 1/18/26 showed no documentation that the physician or nurse practitioner was notified that the ordered insulin was not administered. During an interview, the DON confirmed there was no documentation of provider notification regarding the missed insulin doses and acknowledged that this failure prevented the provider from assessing the resident’s condition and altering treatment as necessary. The admission record confirmed that the resident was admitted on 1/16/26 with a diagnosis of Type 2 diabetes mellitus with hyperglycemia.
Failure to Administer Ordered Lantus Insulin for Newly Admitted Diabetic Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident was free from significant medication errors when ordered Lantus insulin was not administered for three consecutive days. Facility policy on Medication Administration, revised 3/5/26, states that medications are to be administered according to prescriber orders and within ordered time frames. Record review showed an active order dated 1/16/26 for Lantus SoloStar 100 units/mL, 10 units subcutaneously at bedtime, for a resident admitted with Type 2 diabetes mellitus with hyperglycemia. The January 2026 MAR documented that the resident did not receive the ordered insulin doses on 1/16/26, 1/17/26, and 1/18/26. Progress notes dated 1/16/26 documented that the Lantus insulin was "pending pharmacy," with no further documentation explaining why the medication was not given. However, the Consolidated Delivery Sheets showed that Lantus SoloStar was delivered to the facility on 1/16/26 and signed for by two nurses. During a telephone interview, an LPN who signed for the medication stated she did not recall the resident or the medication and did not know what occurred. The DON confirmed that the insulin was not administered on the three identified days, acknowledged that the progress note indicated staff believed the medication was pending pharmacy, and explained that the nurses who signed for the medication worked on a different unit, making it possible the medication was not taken to the resident’s unit. The DON agreed that failure to administer the medication as ordered could result in adverse outcomes such as hyperglycemia.
Failure to Provide Incontinence Care per Care Plan
Penalty
Summary
The facility failed to provide incontinence care in accordance with the care plan for one resident who was dependent on staff for toileting due to paraplegia and a C5-C7 spinal cord injury. The resident's care plan specified total assistance from two staff members for toileting and incontinence care as needed, due to the resident's self-care performance deficit and risk for skin integrity impairment. Facility policy required that residents unable to perform activities of daily living independently receive appropriate support, including elimination and toileting, in accordance with their care plan. On observation, a CNA verified that the resident's incontinence pad and brief were saturated and showed a light brown ring of dried urine, indicating the resident had not been changed throughout the night. The CNA confirmed the resident had not been changed since the start of her shift. The DON acknowledged that the care plan was not followed, as the resident did not receive the required incontinence care overnight. The resident was cognitively intact and dependent on staff for toileting at the time of the deficiency.
Failure to Provide Timely Incontinent Care for Dependent Resident
Penalty
Summary
A deficiency occurred when a dependent resident did not receive timely assistance with activities of daily living, specifically incontinent care. The facility's policy requires that residents unable to perform ADLs independently receive necessary support, including toileting and elimination care. On the morning of the survey, the resident reported that a CNA did not check or change him during the night, and that staff would leave him wet if he was asleep. Observation confirmed that the resident's incontinence pad and brief were saturated with urine, with a visible light brown ring indicating prolonged exposure. The CNA assigned to the resident acknowledged that the resident had not been changed as required. Further interviews with the DON and ADON confirmed that residents should be checked and provided incontinent care at least every two hours, and agreed that the resident's condition indicated care had not been provided in a timely manner. The resident, who was admitted with paraplegia and assessed as cognitively intact but dependent with toileting, did not receive the necessary assistance as outlined in facility policy.
Failure to Update Care Plan with Preventative Interventions After Multiple Falls
Penalty
Summary
The facility failed to update and revise the care plan for a resident after multiple falls, as required by its own Fall Prevention Program policy. The policy specifies that all residents should be assessed for fall risk at admission, quarterly, and after any significant change in condition, with the care plan updated to reflect new risks and appropriate interventions. Despite the resident experiencing five separate falls, the care plan only documented post-fall actions such as neuro checks and notifications to responsible parties and medical staff, without adding or revising any preventative interventions to address the ongoing risk of falls. The resident involved had a history of hemiplegia and hemiparesis following cerebrovascular disease, hypertension, and blindness, and was admitted with these diagnoses. After one of the falls, the resident was found with a laceration and hematoma and required emergency room evaluation. During an interview, the ADON confirmed that no new interventions or care plan revisions were implemented following any of the falls, acknowledging that the care plan should have been updated with new fall prevention strategies after each incident.
Failure to Update Fall Prevention Interventions After Multiple Resident Falls
Penalty
Summary
The facility failed to implement effective supervision and accident prevention interventions for a resident with a documented history of falls and multiple risk factors, including hemiplegia, hemiparesis, hypertension, and blindness. Despite the facility's policy requiring fall risk assessments and updates to the care plan after each fall, the resident experienced five separate falls over a period of several months. After each incident, including one resulting in a laceration and hematoma to the left eyebrow that required emergency department treatment, no new interventions were documented or added to the resident's care plan. Interviews with staff confirmed that the resident's bed was positioned against the wall due to his fall history, but no additional measures were taken after repeated falls. Staff also noted that the resident sometimes pushed against the wall, which may have contributed to the bed shifting and a subsequent fall. The Assistant Director of Nursing acknowledged that the facility did not initiate new interventions following the repeated falls, despite the policy and the resident's ongoing incidents.
CNA Misappropriation of Resident Funds via Cash App and Trust Fund Card
Penalty
Summary
A Certified Nursing Assistant (CNA) misappropriated funds from a resident who was cognitively intact and diagnosed with quadriplegia. The resident began sending money to the CNA via Cash App to purchase food and paid additional fees for this service. In April, the resident provided her trust fund card to the CNA for continued shopping assistance. Over time, the resident noticed unauthorized charges on both her Cash App and trust fund accounts, including transactions that coincided with the CNA's personal activities, such as dining at a restaurant. The resident provided screenshots and account summaries showing numerous unauthorized transactions totaling thousands of dollars. Interviews with facility staff revealed that the standard practice was for Social Services or the Activity Director to shop for residents, and staff were not permitted to take resident debit cards or receive money via Cash App. The resident was unaware of this policy and did not request assistance from these departments. The CNA denied the unauthorized transactions, but evidence from account records and resident testimony identified the CNA as the recipient of the funds. The facility's policy prohibits the misappropriation of resident property or finances, but this policy was not followed in this case, resulting in significant financial loss for the resident.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision and monitoring for a resident identified as high risk for wandering. The resident, who has moderate cognitive impairment, was able to leave the facility without staff noticing for several hours. The resident's wander guard bracelet, which is supposed to alert staff if the resident attempts to leave, malfunctioned and did not trigger an alarm when the resident exited the building. This malfunction was sudden, and previous checks of the bracelet had not revealed any issues. Staff interviews revealed that the resident was last seen by an LPN around lunchtime and was not checked on again until late afternoon, despite being at high risk for wandering. The CNA on duty also confirmed that she did not attempt to locate the resident before her shift ended. The facility's policy on wander management and resident elopement was not effectively implemented, as staff did not monitor the resident frequently enough to prevent the elopement incident.
Failure to Implement Care Plans for EBP and ADL
Penalty
Summary
The facility failed to implement a care plan for Resident #20, who was on Enhanced Barrier Precautions (EBP) due to a deep tissue injury on the left heel and a urinary catheter. During an observation, an LPN performed wound care without donning a gown, which is a requirement under EBP to prevent the spread of infection. The LPN admitted to forgetting the protocol due to nervousness, and the RN confirmed the necessity of EBP for the resident's protection. Additionally, the facility did not follow the care plans for Residents #38 and #80 regarding activities of daily living (ADL). Resident #38, who had moderate cognitive impairment, was observed with long, jagged nails and facial hair, indicating neglect in personal hygiene care as outlined in her care plan. Similarly, Resident #80, who was cognitively intact but had left side hemiparesis, was found with excessively long and dirty fingernails, suggesting that the care plan for nail care was not implemented. Both residents' care plans included specific interventions for personal hygiene that were not followed, as confirmed by staff interviews.
Failure to Provide Necessary Grooming and Hygiene Services
Penalty
Summary
The facility failed to provide necessary grooming and personal hygiene services for two residents who were unable to self-perform activities of daily living (ADLs). Resident #38 was observed with long, jagged nails and facial hair, which she expressed a desire to have trimmed and shaved. Despite informing staff of her preferences, these grooming needs were not addressed. The Director of Nursing (DON) acknowledged the responsibility of the staff to ensure residents' grooming needs are met and confirmed the facility's failure to provide the desired ADL care for Resident #38, who has a moderate cognitive impairment. Similarly, Resident #80 was found with excessively long, jagged fingernails with a dark brown substance underneath. He expressed a desire to have his nails cut and cleaned, having asked staff multiple times without success. The LPN and Infection Control Nurse confirmed the potential risk of self-injury and infection due to the untrimmed nails. The DON acknowledged Resident #80's request for nail care, and the facility's records showed no documentation of care refusals. Resident #80 is cognitively intact and requires assistance with personal hygiene due to quadriplegia.
Failure to Cover Urinary Catheter Bag Compromises Resident Dignity
Penalty
Summary
The facility failed to provide a resident with a dignified existence by not covering a urinary catheter bag, as required by their policy. The policy, titled 'Protocol for Keeping Catheter Bags Covered for Dignity Purposes in a Nursing Home,' mandates that catheter bags should be covered with an appropriate, discreet cloth or garment to maintain the dignity, privacy, and comfort of residents. However, observations revealed that Resident #20's catheter bag was left uncovered on multiple occasions, making the urine visible. This was confirmed during an interview with the resident, who expressed discomfort and a desire for the bag to be covered. Further investigation showed that Resident #20 had an order effective from 10/31/24 for a privacy bag or covering over the urine collection bag for dignity. Interviews with LPN #4 and RN #2 confirmed that the facility typically used blue privacy urinary bags for residents with catheters, but Resident #20's bag, which was uncovered, likely came from the hospital. Both staff members acknowledged the dignity issue and agreed that the situation should have been addressed. Resident #20, who was cognitively intact with a BIMS score of 14, had been admitted with diagnoses including Malignant Neoplasm of the Uterus and Type 2 Diabetes Mellitus.
Inaccessible Call Light for Cognitively Intact Resident
Penalty
Summary
The facility failed to ensure that a call light device was accessible for a dependent resident, identified as Resident #7. During an observation and interview, the resident stated that he used the call light to receive assistance for his care, but it was not within his reach. The call light cord was found twisted around the bed frame under the foot of the resident's bed, making the call light button inaccessible. A Certified Nursing Assistant (CNA) confirmed that the call light was not where the resident could reach it and proceeded to untangle the cord. A Registered Nurse (RN) also confirmed the inaccessibility of the call light and acknowledged that it should have been secured within the resident's reach. Resident #7 was admitted to the facility with diagnoses including Type 2 Diabetes Mellitus, Hypertensive Heart Disease with heart failure, Chronic Obstructive Pulmonary Disease, and a history of repeated falls. The resident was cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 14. The Director of Nursing (DON) confirmed that staff members were responsible for ensuring the call light was clipped to the bedding within the resident's reach, acknowledging the facility's failure to do so in this instance.
Unresolved Grievances Over Missing Clothes in LTC Facility
Penalty
Summary
The facility failed to resolve grievances related to missing clothing items for four residents, as identified during resident and staff interviews, record reviews, and facility policy reviews. The facility's policy on filing grievances and complaints, revised in June 2024, states that all grievances or recommendations from resident or family groups concerning issues of resident care will be considered and responded to in writing if requested. However, the Resident Council minutes revealed ongoing complaints about missing clothes on multiple occasions, including meetings held in May, June, August, September, and November 2024. Interviews with residents during a Resident Council meeting in November 2024 confirmed that the issue of missing clothes had been a persistent problem, with residents expressing concerns about missing items such as compression socks, jogging suits, and new ankle socks. Interviews with facility staff, including the Activity Director, Housekeeper/Laundry staff, and the Licensed Social Worker (LSW), confirmed that the issue of missing clothes had been ongoing and unresolved. The Activity Director stated that she notified the LSW and laundry staff about the issue after each Resident Council meeting, but the problem persisted. The Housekeeper/Laundry staff suggested that the issue might be due to laundry backlogs and clothes not being labeled with residents' names. The Administrator acknowledged awareness of the problem and admitted that efforts had been made to address it, but it remained unresolved. All four residents involved were cognitively intact, as indicated by their Minimum Data Set (MDS) assessments, with scores reflecting their cognitive status.
Discrepancy in Resident's Code Status Documentation
Penalty
Summary
The facility failed to ensure the accuracy of a resident's code status in the physician orders, which led to a discrepancy between the resident's advance directive and the physician's order. Specifically, the advance directive signed by the resident's family member indicated a preference to decline CPR, while the physician's order listed the resident as a full code, meaning CPR would be performed. This inconsistency was identified during a review of the resident's records and confirmed through staff interviews. Interviews with facility staff, including a registered nurse and the admissions coordinator, revealed that in the event of an emergency, staff would rely on the electronic medical record to determine the resident's code status. The admissions coordinator confirmed that the resident's family had elected for a DNR status, and the social services staff acknowledged the potential for the resident to be resuscitated against their wishes due to the mismatch in documentation. The facility did not have a policy in place to address discrepancies between advance directives and physician orders, contributing to the deficiency.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations of unsanitary conditions in resident rooms. On two separate survey days, surveyors noted a persistent smell of urine and the presence of a dark brown substance, suspected to be feces, in room [ROOM NUMBER]-P. Despite cleaning efforts by housekeeping staff, the substance remained on the bathroom floor, commode, and recliner. Interviews with housekeeping staff and CNAs revealed a lack of clarity and training regarding responsibilities for cleaning bodily fluids, contributing to the unsanitary conditions. In another room, [ROOM NUMBER], surveyors observed a large dried brown substance on the toilet bowl and a dark brown substance on the floor under the bed. The privacy curtain was improperly hung, and a black substance was noted around the door frame. Housekeeping staff confirmed these observations and acknowledged the need for thorough cleaning, indicating that the room had not been adequately maintained. Additionally, room [ROOM NUMBER]-W had an air conditioner unit with a black substance on the vents and control panel, which was confirmed by the RN Supervisor to be potentially harmful if inhaled. The facility's housekeeping practices, including deep cleaning schedules, were insufficient to address these issues. Furthermore, a large brown discolored area on the ceiling tiles at the end of the 200 hall was identified as a leak from an air conditioning unit, which had not been addressed by maintenance staff, further compromising the facility's environment.
Failure to Monitor Anticoagulant Therapy in Resident
Penalty
Summary
The facility failed to monitor a resident receiving anticoagulant medication for signs of bruising and bleeding, which is a requirement to ensure each resident's drug regimen is free from unnecessary drugs. The facility's policy titled Anticoagulation-Clinical Protocol, revised in November 2018, mandates monitoring for possible complications in individuals on anticoagulation therapy. However, a review of Resident #47's records revealed that there was no monitoring tool in place for staff to observe signs of bruising and bleeding associated with the anticoagulant medication Apixaban, prescribed for Peripheral Vascular Disease. Interviews with staff confirmed the deficiency. An LPN acknowledged that Resident #47 was on an anticoagulant and confirmed the absence of a monitoring task on the resident's MAR for bruising or signs of bleeding. The DON also confirmed that the resident was not being adequately monitored for potential outcomes associated with anticoagulation medications, despite the necessity of such monitoring. Resident #47 was admitted with medical diagnoses including Peripheral Vascular Disease, highlighting the importance of monitoring due to the prescribed anticoagulant therapy.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure the proper storage of drugs as evidenced by a medication cart being left unlocked during medication administration. An observation revealed that an LPN left the medication cart outside a resident's room with the medication drawers facing outward. The cart was unattended and unlocked for approximately 15 minutes while the LPN was inside the room administering medications. During this time, a resident was sitting beside the cart in a wheelchair, and two other residents self-propelled themselves by the cart, creating a potential risk for unauthorized access to medications. Interviews with facility staff confirmed the deficiency. The LPN acknowledged that the medication cart was supposed to be locked at all times unless the nurse was present and preparing medications for administration. An RN further confirmed that the medication carts should be locked to prevent unauthorized access when unattended. The RN stated that the only time the cart should be unlocked is when the nurse is actively retrieving medications. This incident highlights a breach in the facility's policy regarding the secure storage of medications.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident who required them due to having a wound and an indwelling medical device. During an observation, a Licensed Practical Nurse (LPN) performed wound care on the resident's left heel without donning a gown, which is a requirement under the facility's EBP policy. The LPN acknowledged knowing the EBP protocol but admitted to forgetting to wear the gown due to nervousness. The purpose of EBP, as stated by the LPN, is to prevent the spread of infection and protect both residents and staff. The resident in question had a urinary catheter and a deep tissue injury on the left heel, necessitating the use of EBP. The resident's care plan explicitly stated the need for EBP during wound care. The Registered Nurse (RN) confirmed that the LPN should have worn gloves and a gown while providing care. The resident's medical history included a malignant neoplasm of the uterus, pressure-induced deep tissue damage of the left heel, and type 2 diabetes mellitus. The resident was cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 14.
Failure to Prevent Elopement of High-Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a delusional resident identified as high risk for elopement. The resident, who had a history of wandering and was cognitively intact but delusional, managed to disassemble his bedroom window and leave the facility undetected. He was found several miles away by local law enforcement approximately 5.5 hours after he was last seen by a Certified Nursing Assistant (CNA). The resident had previously attempted to leave the facility and had been given a wander guard, which he removed before exiting through the window. Interviews with staff revealed that the resident had voiced delusional statements about needing to leave for a job and had previously attempted to leave the facility through the front door. Despite being identified as a high-risk wanderer and having a wander guard, the facility's measures were insufficient to prevent his elopement. The resident's care plan had been updated multiple times to reflect his high risk for elopement, but these measures did not prevent the incident. The facility's failure to provide adequate supervision and secure the resident's environment led to the resident's unsupervised and unwitnessed departure. The resident was found safe but delusional and was placed on one-to-one observation upon his return. The facility's policies and procedures for monitoring high-risk residents were found to be inadequate, leading to the identification of Immediate Jeopardy and Substandard Quality of Care by the State Agency.
Removal Plan
- LPN #1 made rounds and Resident #1 was not present in his room and his window was disassembled.
- LPN #1 initiated a facility elopement drill. Resident #1 was not located in the facility and all residents were accounted for.
- The Administrator was notified by LPN #1 of Resident #1 missing from facility.
- The Director of Nurses was notified by the Administrator of Resident #1 missing from the facility.
- The local Police Department was notified by RN Supervisor #1 of Resident #1 missing from the facility.
- The facility Administrator was notified by the Sheriff Department that Resident #1 had been located.
- The Administrator and Director of Nurses picked up Resident #1 at local dispatch office.
- The RN Supervisor #1 conducted a head-to-toe body assessment on Resident #1 to review for any skin abnormalities or concerns. Resident #1 had no negative skin issues or concerns.
- The DON oversaw verification of all residents in facility using census. The census in the facility was 149 with 2 residents in the hospital. All 149 residents were accounted for or verified.
- Resident #1 was placed on 1:1 monitoring.
- The wander guard bracelet was verified to work properly by checking function with door alarm by DON, and then placed on Resident #1's left wrist.
- The facility staff was interviewed by the Administrator to determine the timeline of events leading up to Resident #1's exit of facility. Statements were collected.
- Staff present in the facility during the time of Resident #1 exit, received immediate in-service by the DON and Administrator on the Elopement procedures, Abuse/Neglect, Vulnerable Adult Act and Rounding.
- All required state agencies were notified of Resident #1 elopement.
- Maintenance assessed Resident #1's window. Window glass appeared intact and window stopper in place. Maintenance reassembled window and inserted additional safety mechanisms to prevent window from being disassembled in the future by Resident #1.
- The LPN #1 initiated facility-based incident reporting on Resident #1.
- Maintenance initiated an audit of all 1st floor windows to ensure they are intact and functioning properly. All windows were intact and functioning properly. Maintenance initiated adding additional safety mechanisms to prevent window from being disassemble from frame.
- The Nurse Practitioner was notified by the RN Supervisor #1 of Resident #1 elopement and return to the facility.
- Resident #1 Responsible Party was notified by the Administrator that Resident #1 had been returned to the facility.
- Licensed nurses were notified to perform acute charting on Resident #1 every shift for the next 72 hours to review resident's physical, mental, and psychosocial needs.
- The DON completed a post Elopement incident. Resident #1 remains high risk for Elopement.
- The Social Services Director followed up on resident's psychosocial needs and will continue for the next 72 hours.
- The Social Services Director reviewed the wander and elopement binders to ensure all are reflective of results.
- Resident #1 was assessed by Psychiatric NP.
- A Quality Assurance Committee Meeting was held with the Medical Director, Administrator, Assistant Administrator, Director of Nursing/Infection Preventionist, and the Assistant Director of Nursing to discuss Resident #1 elopement along with plan of correction.
- The Assistant Director of Nursing audited current high-risk wander patients to review orders and care plans for accuracy. There are currently six wander patients.
- The RN Supervisor #2 performed an elopement drill to review and educate night shift on policies and procedures on elopement.
- The RN Supervisor #1 performed an elopement drill to review and educate evening shift on policies and procedures on elopement.
Failure to Transport Resident for Critical Surgery
Penalty
Summary
The facility failed to ensure the right to be free from neglect when it did not transport a dialysis resident to a scheduled surgical procedure to ligate an arteriovenous (AV) fistula. This failure resulted in the resident being admitted to the hospital with a bleeding aneurysm of the AV fistula, requiring a blood transfusion of four units of blood. The incident was identified as Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) by the State Agency (SA), which began when the facility neglected to transport the resident to the appointment, placing the resident and others in a situation likely to cause serious harm or death. The facility's policy on abuse prohibition, revised in November 2023, was intended to prevent neglect, but the facility had no specific policy related to appointments. The resident's medical records indicated that the dialysis clinic had communicated the importance of the surgical procedure scheduled for March 21, 2024, to the facility. However, the facility staff failed to follow up on the appointment time, leading to the resident missing the surgery. The resident subsequently experienced severe bleeding from the AV fistula site and was admitted to the hospital with acute blood loss anemia. Interviews with facility staff revealed a breakdown in communication and follow-up regarding the resident's appointments. The agency LPN handed over the appointment information to the charge nurse, who then passed it to the Appointment Scheduler. Despite multiple confirmations from the dialysis clinic about the critical nature of the appointments, the facility staff did not ensure the resident was transported for the surgery. This failure in communication and follow-up led to the resident's hospitalization and the identification of Immediate Jeopardy by the State Agency.
Removal Plan
- The Interim DON contacted Resident #2 general surgeon office to confirm phone for communication that is currently in their file and provide the facility contact information for any further communication.
- Resident Council Meeting was held with the Activity Director, Assistant Activity Director #1, Assistant Activity Director #2, and Resident Council President, and eighty-two (82) total resident presents to inform them the facility received Immediate Jeopardies.
- The Staff Development initiated in-servicing with all licensed nurses, transportation, front desk receptionist on communication with appointments to include the process with signing resident in and out of facility, the daily transportation log along with the sign out binder. Inservice also includes adding a step to the appointment communication process with Admission Coordinator to review the communication tab within the electronic records to ensure all appointments are listed. No staff will be allowed to return to work without completing.
- The Administrator held a one-to-one in-service with Admission Coordinator on the appointment scheduling process to include communication, scheduling and following up on appointments.
- The Admission Coordinator conducted an audit of current dialysis patients to review for appointments by contacting the dialysis center and verifying any outside appointment to ensure facility followed up correctly. There are currently twelve (12) dialysis patients. All appointments were followed up.
- Medical Director, Administrator, Assistant Administrator, Interim Director of Nursing/ Infection Preventionist, and Assistant Director of Nursing held a Quality Assurance Performance Improvement Meeting to include notification of Immediate Jeopardy to review steps initiated to prevent any further reoccurrence to include audits on elopements, care plans, orientation binder, in-services on appointment process, audits of dialysis residents and contacting dialysis to verify appointments.
- The Assistant Administrator conducted a one-to-one in-service with Front Desk Receptionist to discuss appointment log, resident leave of absence binder, and how to locate current BIMS for residents.
Failure to Revise Care Plan Leads to Resident Elopement
Penalty
Summary
The facility failed to revise the care plan for a severely cognitively impaired resident who eloped from the facility. The resident, who had a history of epilepsy and dependence on a wheelchair, was found approximately eight-tenths of a mile from the facility by police after being away for 81 minutes. The resident's care plan, last revised on 11/02/23, did not reflect his inability to go on leave of absence (LOA) unsupervised despite a Brief Interview for Mental Status (BIMS) score of 5, indicating severe cognitive impairment. Staff interviews confirmed that the resident was no longer allowed to go out unsupervised due to his confusion, but this change was not updated in the care plan until after the elopement incident on 3/31/24. On the day of the incident, an agency LPN opened the door for the resident, mistakenly believing he was going to sit on the front porch. The resident exited the facility at 7:25 PM and was later found by police. The facility's Director of Nursing (DON) and Administrator were notified, and the resident was picked up and returned to the facility. Upon return, the resident was assessed with no injuries noted, and a wander guard bracelet was placed on his wrist. However, the failure to update the care plan in a timely manner directly contributed to the resident's unsupervised exit. Interviews with the Assistant Director of Nursing (ADON) and the Social Worker (SW) confirmed that the resident's BIMS score had been below 12 since 2/22/24, indicating severe cognitive impairment. Despite this, the care plan was not updated to reflect the resident's need for supervision during LOA. The SW acknowledged that the care plan should have been revised when the resident's BIMS score fell below 12, but it was not updated until after the elopement incident. The Interim DON also agreed that the care plan should have been updated at the time the resident was determined to be unsafe to go LOA unsupervised.
Removal Plan
- The interim Director of Nursing (DON) and Licensed Practical Nurse (LPN) #1 conducted a head-to-toe body assessment on Resident #1 to review for any skin abnormalities or concerns. Resident #1 had no negative skin issues or concerns.
- The Interim DON oversaw verification of all residents in facility using census with only one resident out of the facility and currently in the hospital. The census in the facility was 140.
- Staff present in the facility during the time of Resident #1 exit received immediate in-service by the Interim DON and Administrator on the procedures with residents signing out to exit facility to include verification of BIMS (Brief Interview for Mental Status).
- The Interim DON and Administrator initiated servicing with all staff present on Abuse, Neglect, Resident Rights, Vulnerable Adult, and Wandering. Staff Development will continue In-Servicing. No staff will be allowed to return to work without completing.
- Resident #1 wandering evaluation was reviewed by Interim Director of Nursing and indicated low risk for wandering. Resident #1 wandering evaluation was updated by the Interim DON and Administrator.
- The wander guard bracelet was verified to work properly by checking function with door alarm by Administrator, and then placed on Resident #1's left wrist.
- The facility camera was reviewed by the Administrator to determine the timeline of events leading up to Resident #1 exit of facility.
- The Administrator interviewed staff present of Resident #1 leaving the facility unattended. The agency LPN who held the door open stated that she was not aware he could not leave the facility.
- The Mississippi State Department of Health was notified of Resident #1 elopement.
- The Nurse Practitioner (NP) was notified by the Administrator of Resident #1 elopement and return to facility.
- Licensed nurses were notified to perform acute charting on Resident #1 every shift for the next 72 hours to review resident's physical, mental, and psychosocial needs.
- The LPN #1 initiated facility-based incident reporting on Resident #1.
- The Corporate Clinical Specialist (CCS) initiated an audit of the wander risk evaluations on all 140 active residents. Results indicated twelve (12) residents requiring updates to the wander system. All updates were corrected.
- The Social Services Director updated the wander and elopement binders to ensure all are reflective of results.
- The Maintenance Supervisor checked all wander guards to verify all were in correct working order with no issues found.
- The NP placed orders for Resident to obtain Urinalysis, Comprehensive Metabolic Panel, and Complete Blood Count.
- The Administrator performed an elopement drill to review and educate day shift on policies and procedures on elopement.
- Social Services completed a BIMS on Resident #1 which resulted in moderate cognitive impairment of a 9.
- A Quality Assurance Committee Meeting was held with the Medical Director, Administrator, Assistant Administrator, Interim Director of Nursing/Infection Preventionist, and the Assistant Director of Nursing to discuss Resident #1 elopement along with plan of correction.
- Resident #1 was assessed by the NP no issues found and care plan was updated by interdisciplinary team to reflect changes in leave of absence status.
- The Registered Nurse Supervisor #1 performed an elopement drill to review and educate night shift on policies and procedures on elopement.
- The Interim DON and Administrator Assistant performed an elopement Drill and educated staff on day shift.
- The Administrator Assistant developed an orientation binder for all agency staff onboard to be in-serviced on facilities policies and procedures to include wandering, elopement, where to find if a resident is allowed to out leave of absence, and appointment guidelines.
- NP reviewed results of labs ordered and placed an order for Levaquin 750 milligrams one by mouth at bedtime for 7 days related to Urinary Tract Infection to start.
- A current BIMS list will be in the leave of absence binder updated weekly or as needed by Social Services. All residents with BIMS under 12 will not be allowed to leave the facility without supervision.
- The final letter of investigation was sent to the Mississippi State Department of Health.
- The Attorney General was notified regarding the results of the Investigation.
- The Administrator performed an elopement drill to review and educate evening shift on policies and procedures on elopement.
- The Interim DON contacted Resident #2 general surgeon office to confirm phone for communication that is currently in their file and provide the facility contact information for any further communication.
- Resident Council Meeting was held with the Activity Director, Assistant Activity Director #1, Assistant Activity Director #2, and Resident Council President, and eighty-two (82) total resident presents to inform them the facility IJs.
- An in-service was initiated by Staff Development Coordinator on leave of absence process and how to locate residents BIMS. No staff will be allowed to return to work without signing.
- The Administrator held a one-to-one in-service with the Licensed Social Worker on Leave of Absences Care plans to include who can exit facility, supervision needed and process for a change in BIMS (Brief Interview for Mental Status).
- Medical Director, Administrator, Assistant Administrator, Interim Director of Nursing/ Infection Preventionist, and Assistant Director of Nursing held a Quality Assurance Performance Improvement Meeting to include notification of Immediate Jeopardy to review steps initiated to prevent any further reoccurrence to include audits on elopements, care plans, orientation binder, in-services on appointment process, audits of dialysis residents and contacting dialysis to verify appointments.
- Regional Case Mix conducted in-service with Minimum Data Set (MDS) to include implementation, Reviewing, Revising, and Resolving person-centered care plans.
- An audit was initiated by Social Services Director on leave of absence care plans to ensure resident with impaired cognition receive adequate supervision.
- The Assistant Administrator conducted a one-to-one in-service with Front Desk Receptionist to discuss appointment log, resident leave of absence binder, and how to locate current BIMS for residents.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a severely cognitively impaired resident. The resident, who had a Brief Interview for Mental Status (BIMS) score of 5 indicating severe cognitive impairment, was last observed in the facility at 7:25 PM. The resident was able to leave the facility unsupervised and was found approximately 0.8 miles away in the community at 8:41 PM. The resident was outside for approximately 81 minutes before being located by the police and returned to the facility. Interviews with staff revealed that there was no effective communication system in place to inform staff which residents were not allowed to leave the facility unsupervised. The agency nurse who let the resident out was unaware that the resident could not leave the facility alone. Additionally, the facility did not have a policy related to resident leave of absence, and the existing Wanderer Management, Monitoring System & Resident Elopement Protocol was not effectively implemented. The facility's failure to provide adequate supervision and effective communication resulted in the resident's elopement, posing a risk of serious harm, injury, or death.
Removal Plan
- The interim Director of Nursing (DON) and Licensed Practical Nurse (LPN) #1 conducted a head-to-toe body assessment on Resident #1 to review for any skin abnormalities or concerns. Resident #1 had no negative skin issues or concerns.
- The Interim DON oversaw verification of all residents in facility using census with only one resident out of the facility and currently in the hospital. The census in the facility was 140.
- Staff present in the facility during the time of Resident #1 exit received immediate in-service by the Interim DON and Administrator on the procedures with residents signing out to exit facility to include verification of BIMS (Brief Interview for Mental Status).
- The Interim DON and Administrator initiated servicing with all staff present on Abuse, Neglect, Resident Rights, Vulnerable Adult, and Wandering. Staff Development will continue In-Servicing. No staff will be allowed to return to work without completing.
- Resident #1 wandering evaluation was reviewed by Interim Director of Nursing and indicated low risk for wandering. Resident #1 wandering evaluation was updated by the Interim DON and Administrator.
- The wander guard bracelet was verified to work properly by checking function with door alarm by Administrator, and then placed on Resident #1's left wrist.
- The facility camera was reviewed by the Administrator to determine the timeline of events leading up to Resident #1 exit of facility.
- The Administrator interviewed staff present of Resident #1 leaving the facility unattended. The agency LPN who held the door open stated that she was not aware he could not leave the facility.
- The Mississippi State Department of Health was notified of Resident #1 elopement.
- The Nurse Practitioner (NP) was notified by the Administrator of Resident #1 elopement and return to facility.
- Licensed nurses were notified to perform acute charting on Resident #1 every shift for the next 72 hours to review resident's physical, mental, and psychosocial needs.
- LPN #1 initiated facility-based incident reporting on Resident #1.
- The Corporate Clinical Specialist (CCS) initiated an audit of the wander risk evaluations on all 140 active residents. Results indicated twelve (12) residents requiring updates to the wander system. All updates were corrected.
- The Social Services Director updated the wander and elopement binders to ensure all are reflective of results.
- The Maintenance Supervisor checked all wander guards to verify all were in correct working order with no issues found.
- The NP placed orders for Resident to obtain Urinalysis, Comprehensive Metabolic Panel, and Complete Blood Count.
- The Administrator performed an elopement drill to review and educate day shift on policies and procedures on elopement.
- Social Services completed a BIMS on Resident #1 which resulted in moderate cognitive impairment of a 9.
- A Quality Assurance Committee Meeting was held with the Medical Director, Administrator, Assistant Administrator, Interim Director of Nursing/Infection Preventionist, and the Assistant Director of Nursing to discuss Resident #1 elopement along with plan of correction.
- Resident #1 was assessed by the NP no issues found and care plan was updated by interdisciplinary team to reflect changes in leave of absence status.
- The Registered Nurse Supervisor #1 performed an elopement drill to review and educate night shift on policies and procedures on elopement.
- The Interim DON and Administrator Assistant performed an elopement Drill and educated staff on day shift.
- The Administrator Assistant developed an orientation binder for all agency staff onboard to be in-serviced on facility's policies and procedures to include wandering, elopement, where to find if a resident is allowed to out leave of absence, and appointment guidelines.
- NP reviewed results of labs ordered and placed an order for Levaquin 750 milligrams one by mouth at bedtime for 7 days related to Urinary Tract Infection to start.
- A current BIMS list will be in the leave of absence binder updated weekly or as needed by Social Services. All residents with BIMS under 12 will not be allowed to leave the facility without supervision.
- The final letter of investigation was sent to the Mississippi State Department of Health.
- The Attorney General was notified regarding the results of the Investigation.
- The Administrator performed an elopement drill to review and educate evening shift on policies and procedures on elopement.
- The Interim DON contacted Resident #2 general surgeon office to confirm phone for communication that is currently in their file and provide the facility contact information for any further communication.
- Resident Council Meeting was held with the Activity Director, Assistant Activity Director #1, Assistant Activity Director #2, and Resident Council President, and eighty-two (82) total resident presents to inform them the facility received Immediate Jeopardies.
- An in-service was initiated by Staff Development Coordinator on leave of absence process and how to locate residents BIMS. No staff will be allowed to return to work without signing.
- The Administrator held a one-to-one in-service with the Licensed Social Worker on Leave of Absences Care plans to include who can exit facility, supervision needed and process for a change in BIMS (Brief Interview for Mental Status).
- Medical Director, Administrator, Assistant Administrator, Interim Director of Nursing/ Infection Preventionist, and Assistant Director of Nursing held a Quality Assurance Performance Improvement Meeting to include notification of Immediate Jeopardy to review steps initiated to prevent any further reoccurrence to include audits on elopements, care plans, orientation binder, in-services on appointment process, audits of dialysis residents and contacting dialysis to verify appointments.
- Regional Case Mix conducted in-service with Minimum Data Set (MDS) to include implementation, Reviewing, Revising, and Resolving person-centered care plans.
- An audit was initiated by Social Services Director on leave of absence care plans to ensure resident with impaired cognition receive adequate supervision.
- The Assistant Administrator conducted a one-to-one in-service with Front Desk Receptionist to discuss appointment log, resident leave of absence binder, and how to locate current BIMS for residents.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
