Butterfield Trail Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Fayetteville, Arkansas.
- Location
- 1923 East Joyce Blvd, Fayetteville, Arkansas 72703
- CMS Provider Number
- 045125
- Inspections on file
- 20
- Latest survey
- December 5, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Butterfield Trail Village during CMS and state inspections, most recent first.
A facility failed to ensure that nurses and nurse aides were competent in responding to medical emergencies, including the use of emergency equipment and CPR. A resident with multiple serious conditions and a full code status experienced a respiratory emergency and fall, but staff did not initiate CPR or use an Ambu bag due to lack of training and uncertainty about equipment location. Facility records showed no regular training, no tracking of CPR certification, and no code team assignments, resulting in an uncoordinated and inadequate emergency response.
A sealed bottle of liquid opioid pain medication prescribed for a resident was found opened and partially used, with no documentation of administration and no sign-out in the controlled medication log. Staff discovered the missing seal and a syringe with residue matching the medication, but were unable to determine who accessed the medication or how it was removed. The resident, who had multiple chronic conditions and moderate cognitive impairment, did not receive any doses of the medication, and the facility's policies did not adequately address misappropriation of property or secure handling of medication keys.
A resident in an LTC facility experienced a seizure due to missed doses of an anticonvulsant medication. The facility's policy required immediate documentation of medication administration, but an LPN signed off on a dose that was not administered, and another dose was not documented. Interviews revealed that improper documentation and communication between nurses led to the error, resulting in the resident not receiving two critical doses.
A resident with severe cognitive impairment did not receive pain medication according to professional standards due to a pharmacy packaging error. The pharmacy packaged two tablets per bubble pouch for a medication order requiring one tablet, and the bubble package was mislabeled as a scheduled medication. This led to confusion among nursing staff, with inconsistent practices in administering the medication.
The facility failed to maintain the dignity of two residents during care procedures. A resident with Alzheimer's received a wound dressing change in a public dining area, while another resident with severe cognitive impairment and impaired vision was given an insulin injection in a room with the door open and window blinds not closed, exposing them to public view. Both actions were acknowledged by staff as inappropriate and contrary to privacy and dignity policies.
A resident with coronary obstructive pulmonary disease and congestive heart failure was observed receiving oxygen therapy without a physician's order, contrary to facility policy. The resident was seen receiving oxygen at 5 liters per minute, and later at 4.5 liters per minute, via nasal cannula. Interviews with the RN and DON confirmed the absence of a physician's order for the oxygen administration, highlighting a failure to adhere to the requirement for medications to be administered only upon a written order.
A resident with Alzheimer's and diabetes received wound care at a dining table, violating infection control protocols. An LPN changed the dressing without a barrier, and the table was not disinfected afterward. Interviews with staff confirmed the inappropriateness of the location due to infection control and dignity concerns.
A resident with a history of transient cerebral ischemic attack was discharged without a required discharge summary, as per the facility's policy. The resident, who was cognitively intact and had a care plan supporting discharge to a non-nursing home level of care, did not receive the necessary discharge documentation and education. The DON confirmed the absence of a discharge summary, highlighting a deficiency in the discharge process.
Failure to Ensure Staff Competency in Medical Emergencies and Emergency Equipment Use
Penalty
Summary
The facility failed to ensure that nurses and nurse aides possessed the necessary competencies to provide appropriate care during medical emergencies, specifically in life-threatening situations requiring emergent intervention and the use of emergency medical equipment. The facility's assessment and competency evaluation processes did not include any plan or method to identify, assess, or evaluate staff competency in handling medical emergencies. Review of facility documents, including the education calendar, nurse skills checklists, and competency fair sheets, revealed no scheduled or documented training for CPR, BLS, mock codes, or emergency equipment usage. Additionally, job descriptions for nursing staff did not require CPR certification, and there was no system in place to track or verify which staff members held current certifications. A critical incident involved a resident with multiple complex diagnoses, including congestive heart failure, COPD, and acute kidney failure, who was admitted for ongoing care of an unstable condition and had a documented full code status. During a medical emergency, the resident experienced severe shortness of breath and subsequently suffered a fall with a head injury. Staff responses were delayed and uncoordinated; LPNs on the scene did not initiate CPR or use available emergency equipment such as an Ambu bag, citing uncertainty about equipment location and lack of training. Interviews with staff revealed that not all nurses were CPR certified, some were unaware of the location or existence of emergency equipment, and no code team assignments or mock code drills had been conducted. The facility's policies required CPR/BLS training and the maintenance of emergency equipment, but these were not implemented in practice. Further interviews with facility leadership, including the DON, Administrator, and Medical Director, confirmed that there was no systematic approach to ensuring staff competency in emergency response. The facility did not maintain a list of staff with current CPR certification, did not assign code teams or designate responsibilities during shifts, and did not provide staff with quick-reference materials for emergency procedures. The lack of accessible emergency equipment and absence of regular training or drills contributed to staff uncertainty and inadequate response during the resident's medical emergency.
Failure to Secure and Account for Controlled Medication
Penalty
Summary
The facility failed to maintain the integrity and security of a sealed controlled medication prescribed for a resident. A bottle of liquid opioid pain medication, which was supposed to be sealed and stored securely by staff, was found opened with part of its contents missing. The medication had been received from the pharmacy in a sealed container and was stored in its original packaging along with a syringe. No doses of the medication were documented as administered to the resident, and the medication administration record and controlled medication log both showed zero doses given. Staff interviews revealed that the seal on the medication bottle was missing, and a syringe with blue liquid residue matching the medication was found inside the box. The facility's Director of Nursing (DON) and LPNs confirmed that the medication had not been signed out or administered, and the missing seal could not be located. The DON determined that approximately 3ml of the opioid medication was unaccounted for. The facility's policies required medications to be stored in their original containers and locked compartments, but there was a lack of clear procedures regarding the handling of keys during staff breaks, and the policy on abuse and neglect did not specifically address misappropriation of property. The resident involved had multiple chronic conditions, including moderate cognitive impairment, and was on hospice care with an order for the opioid medication as needed for pain or shortness of breath. Despite the medication being prescribed and available, it was not administered, and the missing medication was not accounted for through proper documentation or investigation. The incident was reported, and staff drug testing was conducted, but the facility was unable to determine who accessed the medication or how the seal was broken.
Medication Administration Error Leads to Resident Seizure
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by the case of Resident #1. The facility's policy required that all medications administered to a resident be documented on the Medication Administration Record (MAR) immediately after administration. However, it was found that the 8:00 AM dose of an anticonvulsant medication on 08/25/2024 was signed off by LPN #3 but not actually administered, as there was no record of the medication being signed out in the narcotic book. Additionally, the 6:00 PM dose on 08/27/2024 was not signed off as administered. This lapse in medication administration led to Resident #1 experiencing seizure-like activity, necessitating emergency medical intervention. Interviews with the Director of Nursing (DON) and LPN #3 revealed that the medication errors were likely due to improper documentation practices and a lack of communication between nurses. The DON explained that nurses sometimes documented medications for each other, leading to confusion and missed doses. LPN #3 admitted to possibly documenting the medication without administering it, and there were no discrepancies noted in the narcotic counts, indicating the medication was not pulled. As a result, Resident #1 did not receive two doses of the anticonvulsant medication, which was crucial for controlling seizures, as confirmed by the hospital records following the incident.
Medication Dispensing Error Due to Mislabeling and Packaging
Penalty
Summary
The facility failed to dispense a pharmacy bubble packaged pain medication according to professional standards for a resident with severe cognitive impairment and multiple diagnoses, including dementia and osteoarthritis. During a medication administration pass, an LPN discovered that the pharmacy had packaged two tablets in each bubble pouch for a medication order that required only one tablet. The LPN attempted to contact the pharmacy to investigate the discrepancy but was initially unsuccessful. The resident's care plan indicated a risk for pain, and the physician's orders specified a scheduled dose of 325mg every 12 hours and an as-needed dose of 650mg every 4 hours. However, the medication administration record showed that only the scheduled doses were administered, and no as-needed doses were given. Further investigation revealed that the bubble package was mislabeled with a blue dot, indicating a scheduled medication, when it was actually for the as-needed order. The Director of Nursing confirmed that nurses might have been using a stock bottle for the scheduled dose. Interviews with other LPNs revealed inconsistent practices, with some leaving one tablet in the open bubble package for the next shift, while others wasted the second tablet. The packaging error and mislabeling led to confusion among the nursing staff, potentially risking medication errors.
Failure to Maintain Resident Dignity During Care
Penalty
Summary
The facility failed to maintain the dignity of Resident #42 during wound care. The resident, who had severe cognitive impairment due to Alzheimer's Disease, was observed receiving a dressing change for a skin tear on the left forearm in the dining room, where other residents were present. This action was contrary to the facility's policy on maintaining privacy and dignity during care, as acknowledged by the LPN involved, who admitted that the dressing should not have been changed in a public area. Similarly, the facility did not ensure the dignity of Resident #11 during insulin administration. The resident, who also had severe cognitive impairment and impaired vision, was given an insulin injection in their room with the door open and the window blinds not closed, exposing the resident to the view of others in the dining room and the parking lot. The LPN administering the injection acknowledged that privacy should have been provided. The Infection Preventionist and the Director of Nursing confirmed that such actions were inappropriate and violated the residents' right to dignity and privacy.
Oxygen Administered Without Physician's Order
Penalty
Summary
The facility failed to ensure that oxygen was administered only when ordered by a physician, which could potentially lead to respiratory complications for a resident. The resident, who was admitted with coronary obstructive pulmonary disease and congestive heart failure, was observed receiving oxygen therapy without a physician's order. The facility's policy requires medications, including oxygen, to be administered only upon a written order from a licensed prescriber. However, a review of the resident's records revealed no such order for oxygen therapy. During observations, the resident was seen receiving oxygen at 5 liters per minute, and later at 4.5 liters per minute, via nasal cannula. Interviews with the RN and the DON confirmed that there was no physician's order for the oxygen administration. The RN acknowledged that oxygen should be administered according to a physician's order, and the DON confirmed that a resident should not receive oxygen without an order. Despite the care plan allowing for hospice nurse intervention, there was no documentation of a physician's order for the oxygen therapy being administered.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to maintain proper infection control practices during wound care for a resident with Alzheimer's disease and type 2 diabetes. The resident, who had severe cognitive impairment and was at risk for skin breakdown, was observed receiving wound care at a dining table in the facility's dining room. The Licensed Practical Nurse (LPN) applied a dressing to the resident's left arm without using a barrier for supplies, and the table was not cleaned or disinfected after the procedure. This action was contrary to the facility's infection control goals, which emphasize minimizing the transmission of pathogens and disinfecting environmental surfaces. Interviews with the LPN, the Infection Preventionist (IP), and the Director of Nursing (DON) confirmed that the dressing change should not have occurred in the dining room due to infection control and dignity concerns. The IP and DON highlighted that performing wound care in a dining area could lead to contamination of the wound and the dining environment. The resident's family member also noted that the resident was on a blood thinner and had a tendency to pick at scabs, which could exacerbate the risk of infection. The facility's failure to adhere to proper infection control protocols during wound care was identified as a deficiency.
Failure to Provide Discharge Summary for Resident
Penalty
Summary
The facility failed to provide a discharge summary for a resident, identified as Resident #45, at the time of a planned discharge. According to the facility's policy titled 'Transfer or Discharge, Preparing a Resident for,' a post-discharge plan should be developed and reviewed with the resident or their family at least 24 hours before discharge. The policy also states that nursing services are responsible for preparing the discharge summary and post-discharge plan, obtaining discharge orders, and providing the resident or their representative with the required documents. However, during an interview, the Director of Nursing (DON) revealed that there was no discharge summary prepared for Resident #45, indicating a lapse in following the facility's discharge procedures. Resident #45 was admitted with a diagnosis of transient cerebral ischemic attack and had a BIMS score indicating cognitive intactness. The resident had a care plan that included a desire to be discharged to a non-nursing home level of care, with family support for the discharge. Despite this, there was no active discharge planning for the resident to return to the community. A physician's order allowed for a trial discharge home, but the necessary discharge summary and educational materials were not provided to the resident or caregiver, as confirmed by the social worker. This oversight in documentation and communication represents a deficiency in the facility's discharge process.
Latest citations in Arkansas
Two residents with moderate cognitive impairment and independent mobility were repeatedly seeking each other’s attention and were found by a CNA on the floor with their pants down, appearing to be engaged in consensual sexual activity. Staff separated them and returned them to secure units, and an LPN reported there was no plan for a consensual sexual relationship or private time, despite awareness of prior similar behavior. Both residents described themselves as being in a loving relationship, but the facility completed no assessments related to sexual activity, made no related care plan revisions, and obtained no orders for contraception, STD testing, or specialty consults. Conversations held by leadership with the residents about privacy and protection were not documented, and there was no facility policy addressing resident sexual relations, despite a general resident rights policy referencing self-determination and support in exercising rights.
The facility failed to develop and implement comprehensive care plans addressing sexual health and a consensual sexual relationship for two cognitively impaired, independently mobile residents with psychiatric and neurological diagnoses. Both residents were known to seek each other’s attention and had a prior relationship, yet their care plans only directed staff to separate and redirect them, without any individualized interventions for sexual health, privacy, or safe sex. A CNA later found the two residents on the floor with their pants down, appearing to engage in consensual sexual activity, and they were separated by staff. Subsequent staff interviews confirmed there was no documented assessment, no care plan revisions for sexual health or the relationship, no safe sex education, no established access to contraception, and no facility policy on resident sexual relations.
A resident with hemiplegia, hemiparesis, a below-knee amputation, moderate cognitive impairment, and wheelchair dependence was transported in a facility van by a CNA who had previously been in-serviced and skills-checked on van safety. During the trip, the CNA secured only three of the four required wheelchair floor locks, and a hold-down device had been removed from the van and not replaced. As the CNA drove over a road irregularity and braked, the incompletely secured wheelchair tilted backward, causing the resident to fall onto the van floor and report head pain with a nodule at the base of the skull. Facility policy required an environment free from accident hazards and staff competency in preventing avoidable accidents, but the missing tie-down and failure to fully secure the wheelchair led to this transport-related fall.
Surveyors found that the facility failed to follow physician orders for PICC line dressing changes, wound care, and catheter care for two residents. One resident with osteomyelitis, pressure ulcers, and an indwelling catheter had multiple missing entries on the TAR for ordered PICC line dressing changes, daily pressure ulcer treatments to the heel and coccyx, and catheter care every shift, with the DON confirming that blank TAR blocks indicated treatments were not completed. Another resident with a PICC line for antibiotic therapy had an order for weekly dressing changes, but the dressing was not changed as scheduled, the PICC site was left uncovered for several minutes during medication administration, and an LPN admitted initialing the TAR to indicate a dressing change that she had not performed, while the TN and APN confirmed the order required adherence to the weekly schedule.
A resident with MRSA colonization and a PICC line for IV antibiotics experienced multiple breaches in infection control by nursing staff. An LPN repeatedly double-gloved, handled room surfaces, trash can lids, and the medication cart, then donned new gloves without performing hand hygiene before preparing and administering oral and IV medications. During PICC access, the LPN wiped the access port for only a few seconds, allowed IV tubing to touch bedding, let the access port fall onto the resident’s arm, and then re-accessed the line without hand hygiene or glove changes. At another time, the PICC site was left uncovered while a treatment nurse prepared for a dressing change, and the LPN entered without prior hand hygiene, disconnected IV tubing, and flushed the line after only a brief alcohol wipe. Staff interviews showed uncertainty and inconsistency regarding required scrub times, glove use, and dressing change schedules, which conflicted with facility policies and stated expectations for aseptic PICC care and hand hygiene.
A resident with dementia, anxiety, depression, and on hospice had a Durable Power of Attorney, Living Will, and signed DNR order all specifying no CPR, and the face sheet reflected no CPR; however, physician orders, a MD progress note, and the MAR repeatedly listed the resident as full code from admission onward. Nursing staff and leadership (including a RN, LPN, ADON, DON, and the Administrator) acknowledged that while the advance directives and resuscitate/DNR form showed DNR status, the active orders and MAR still indicated full code, even though staff commonly rely on these documents to determine code status, contrary to facility policy requiring alignment of the care plan and physician orders with the resident’s documented treatment preferences.
A resident with depression, insomnia, and non-Alzheimer’s dementia experienced a documented decline from moderate to severe cognitive impairment on successive MDS assessments, but the care plan was not revised and continued to include an active "Sexual Expression" problem allowing engagement in sexual behavior with other consenting residents. This care plan had been initiated after an incident where two residents were found in bed together partially undressed and engaging in intimate behavior. The resident’s responsible party stated the resident was not capable of consenting to sexual activity, an LPN reported the resident could not express needs or make decisions about sexual relationships, and another LPN stated the care plan no longer reflected the resident’s needs due to steady decline. The Social Services Director had previously completed sexual consent questionnaires only at the time of the incident, and the Medical Director indicated that a sexual activity care plan was not appropriate for a resident with a very low BIMS score, while the Administrator acknowledged care plans were expected to be updated when MDS changes occurred.
A resident with traumatic brain injury, stroke history, and altered mental status was placed on a secured unit for elopement risk but had only general care plan interventions that were not updated when new wandering, exit‑seeking, and aggressive behaviors emerged. Over time, staff documented that the resident walked the halls at night, entered other residents’ rooms, voiced not living there, stated plans to leave through a window, followed staff through locked doors, and sought ways to get out after a home visit. Despite an elopement assessment and multiple behavior notes, no individualized elopement‑prevention interventions were added to the care plan. Eventually, during a night shift when a CNA reported dozing off and not re‑checking the room, the resident broke a bedroom window with furniture, left the building, and was later found off‑site by police after nearly being hit by a car, confirming that the care plan had not been effectively revised or implemented to address the resident’s exit‑seeking behaviors.
A resident with traumatic brain injury, altered mental status, and a history of wandering was housed on a locked unit with a care plan identifying elopement risk but focused mainly on therapeutic activities and medication monitoring. After returning from a home visit, the resident exhibited escalating behaviors over several days, including being up all night walking halls, entering other residents’ rooms, standing at locked exits, following staff out locked doors, voicing a desire to leave, and stating a plan to escape through a window. On the night of the incident, camera footage showed the resident moving between the room, day room, and bathroom until entering the room and not re-emerging, while the CNA on duty did not perform checks, reported that staff did not usually re-check the resident once in the room, and admitted to dozing off. The resident broke the bedroom window with furniture, left the building unnoticed, and was later found by police nearly two miles away after a citizen reported almost hitting the resident with a car, demonstrating that the facility failed to provide adequate supervision and monitoring during a period of increased exit-seeking.
Two residents with significant cognitive and neuromuscular/orthopedic conditions experienced falls when staff did not follow care-planned assistance and supervision requirements. One resident, care-planned for two-person assist with bed mobility, transfers, and personal hygiene, was found on the floor after a CNA attempted incontinent care alone. Another resident, care-planned for staff assistance with dressing and two-person assist for transfers with a slide board, was left seated at the edge of the bed and told to dress themself; the resident fell while unattended and was later found on the floor wearing a C-collar. CNAs reported relying on the electronic care plan/Kardex for instructions, but one CNA described unclear and brief initial training on accessing the system, while leadership stated CNAs were expected to verify care needs in the electronic care plan before each care episode.
Failure to Support and Assess Consensual Sexual Relationship Between Residents
Penalty
Summary
The deficiency involves the facility’s failure to support residents’ rights to engage in a consensual sexual relationship between two cognitively impaired residents. Both residents had documented moderate cognitive impairment on their MDS assessments (BIMS scores of 11 and 12) and were independent with mobility. Their care plans identified "inappropriate seeking of other individual's attention" with interventions limited to separating and redirecting them. There was no documented assessment of their capacity for sexual decision-making or sexual activity either before or after an incident in which they were found with their pants down on the floor together. On the date of the incident, a CNA discovered the two residents in a room with their pants down, appearing to be having sex, and reported that it looked like they were consenting and that she had been told they had a history together. The CNA notified an LPN, and the residents were separated and returned to their secure units. The LPN confirmed there was no plan in place to allow a consensual sexual relationship or to provide private time for the residents, despite being aware that similar behavior had occurred previously. Interviews with the residents indicated that they viewed themselves as being in a relationship, that they loved each other, and that they did not intend harm. Record review showed no orders for birth control, sexually transmitted disease testing, or referrals to specialized clinics or physicians for either resident. There was no documentation in progress notes of education or conversations with staff regarding the incident, and no assessments related to sexual activity were completed before or after the event. The MDS nurse and Administrator acknowledged speaking with the residents about the incident and the possibility of providing privacy and protection, but the MDS nurse stated that none of these discussions or interventions were documented and nothing was added to the care plans. The Administrator also stated the facility did not have a policy on resident sexual relations, despite a resident rights policy referencing residents’ rights to self-determination and to be supported in exercising their rights.
Failure to Care Plan for Residents’ Sexual Health and Consensual Relationship
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, measurable care plans addressing sexual health and consensual sexual relationships for two cognitively impaired residents. Resident #3, admitted with traumatic brain injury, bipolar disorder, mood disorder, and an unspecified mental disorder, had a BIMS score of 11 indicating moderate cognitive impairment and was independent with mobility. Resident #4, admitted with schizophrenia, schizoaffective disorder bipolar type, dementia, and psychosis, had a BIMS score of 12, also indicating moderate cognitive impairment, and was independent with mobility. Both residents’ care plans, updated on 03/11/2026, identified “inappropriate seeking of other individuals’ attention,” but the only interventions listed were to separate and redirect, with no individualized care plan addressing their sexual health, their ongoing relationship, or parameters for consensual sexual activity. On 03/11/2026, a CNA discovered Resident #3 and Resident #4 on the floor with their pants down, appearing to be engaged in consensual sexual activity. The CNA notified an LPN, and staff separated the residents and returned them to their secure units. Staff interviews revealed that there was no existing plan for a consensual sexual relationship, no plan for private time, and no documented assessment or care plan interventions related to sexual health, safe sex education, or contraception for these residents, despite knowledge of a prior relationship and the residents’ expressed desire and intent to engage in sexual activity. The MDS nurse and the Administrator acknowledged that no care plan revisions were made to address sexual health or the relationship, no documentation of related discussions or interventions was completed, and the facility had no policy on resident sexual relations and no established interventions for birth control.
Failure to Properly Secure Wheelchair During Van Transport Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s wheelchair was fully and properly secured with all required safety straps before transport in the facility van, resulting in the resident falling backwards in the van. The resident had physician orders for LTC admission and diagnoses including hemiplegia and hemiparesis affecting the right dominant side, as well as an acquired absence of the left leg below the knee. The resident’s MDS showed moderate cognitive impairment, functional limitations in lower extremity range of motion bilaterally, and use of a wheelchair for mobility. The care plan documented a self-care performance deficit requiring limited assistance by one staff for transfers and noted an actual fall earlier in the month, with an intervention for staff education on proper van transport. On the date of the incident, the resident was being transported in the facility van by a CNA who served as the van driver. According to the facility’s reportable and the CNA’s written witness statement, the CNA applied two back floor locks and one front floor lock to secure the wheelchair but did not secure all four required locks. During the drive, as the CNA approached a dip or hump in the road and applied the brakes, the resident’s wheelchair tilted backwards. The resident stated they were falling, and when the CNA stopped the van, she found the resident lying flat on their back on the van floor with the wheelchair also on the floor. Nursing documentation indicated the resident reported pain at the base of the skull, had a nodule on the back of the head, and declined transfer to the emergency room. Interviews and document reviews showed that the CNA had previously received in-service training and skills checkoffs on how to properly secure residents in the van and had signed best-practice forms stating that wheelchairs would be securely attached to the van body and kept centered during transport. The Administrator reported that the CNA admitted she did not use the correct number of straps to secure the wheelchair and that a hold-down device (tie-down/safety strap) had been removed from the smaller van to be used in a larger van and was not replaced. The Maintenance staff confirmed that a hold-down device for the back of the wheelchair was missing from the van used for the transport and that tie-downs were interchangeable between vans. Subsequent observation with other CNAs demonstrated that when all four locks and the seat belt were properly engaged, the wheelchair did not move, but loosening the front locks allowed the wheelchair to move, illustrating how incomplete securement could permit wheelchair movement during transport. The facility’s Safety and Supervision of Residents policy stated that the environment should be made as free from accident hazards as possible and that employees should be trained and demonstrate competency in identifying and preventing accident hazards. Despite this policy and prior in-services, the resident’s wheelchair was not fully secured with all required straps at the time of transport, and a necessary hold-down device was missing from the van, directly contributing to the resident’s fall inside the vehicle.
Failure to Follow Physician Orders for PICC Line, Wound, and Catheter Care
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for PICC line dressing changes, wound care, and indwelling catheter care for two residents. One resident was admitted with osteomyelitis of the vertebra, sacral and sacrococcygeal region, type 2 diabetes mellitus, and a pressure ulcer, and had a BIMS score indicating moderate cognitive impairment. Physician orders included a PICC line dressing change every three days, daily dressing changes to an unstageable right heel pressure ulcer, daily cleansing and dressing of an unstageable coccyx pressure ulcer, and catheter care every shift and PRN with soap and water or wipes for wound healing. Review of the Treatment Administration Record (TAR) for June showed multiple dates where there were no initials or check marks to indicate that the PICC line dressing changes, right heel dressing changes, coccyx pressure ulcer treatments, and catheter care had been completed as ordered. The TAR for this resident showed no documentation of PICC line dressing changes on several specified dates, despite an active order for changes every three days. Similarly, the TAR lacked initials or check marks for the ordered daily dressing changes to the right heel pressure ulcer on multiple dates. For the coccyx pressure ulcer, there were two separate orders—one to cleanse and apply wet-to-dry dressings with a specific brand dressing and island dressing every day shift, and a later order to cleanse and apply wet-to-dry dressings with a specific brand dressing and foam dressing every day shift. On several dates, the TAR contained open blocks with no initials or check marks, indicating that these treatments were not completed. Additionally, the TAR showed that catheter care ordered every shift and PRN was not documented as completed on multiple day shifts over a series of days. The DON confirmed that open blocks on the TAR indicated treatments were not completed. For the second resident, who was admitted with infection and inflammatory reaction due to an internal left hip prosthesis, MRSA, and pain related to orthopedic prosthetic devices, there was an order for a PICC line dressing change to the left upper arm every Wednesday on the day shift. The March TAR reflected this order and showed documented dressing changes on two Wednesdays, with check marks and initials indicating the treatment had been administered. During a medication pass observation, an LPN examined the PICC line dressing and was unsure of the last dressing change date, noting that the handwritten date on the dressing was unclear and that PICC line dressings could only be changed by an RN. Later observation showed the treatment nurse at the bedside with the PICC line site uncovered after the dressing had been removed, while the LPN administered oral medications and hung an antibiotic through the PICC line, leaving the site uncovered for several minutes. The treatment nurse stated the dressing change had been due the previous day but was not completed because the dressing was not available, and also stated she signed the TAR after completing the dressing change. Further interviews revealed documentation discrepancies for this second resident. The DON’s nursing incident/accident note documented that the PICC line dressing change was not completed on the scheduled day and was instead changed the following day. The LPN later acknowledged that the initials on the TAR for the scheduled dressing change date were hers, and admitted she had not changed the dressing but had only looked at it after being told by the treatment nurse that the dressing was within a seven-day time frame. She stated she placed her initials in the TAR block to indicate she had looked at the dressing, even though the TAR coding indicated that initials in the block meant the treatment was given. The treatment nurse reported changing the dressing on one earlier date and, when changing it later, observed a written date on the removed dressing that did not match any documented TAR entry and could not identify whose initials were on that dressing. The treatment nurse and APN both confirmed that the physician’s order required the dressing to be changed every Wednesday and that, even if changed on another day, it still needed to be changed on Wednesday per the order. The DON confirmed that staff initials in a TAR block indicated the treatment was given, an X indicated the treatment was not ordered for that day, and an open block indicated the treatment was not completed.
Improper Hand Hygiene and PICC Line Management During MRSA-Positive Resident Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper infection prevention and control practices during the care of a resident with a PICC line and MRSA colonization. The resident was admitted with diagnoses including infection and inflammatory reaction due to an internal left hip prosthesis, MRSA, and pain related to orthopedic prosthetic devices. The resident had a PICC line in the left arm for IV antibiotic therapy to treat the hip infection, and the care plan included contact isolation, use of gowns and gloves during physical contact, handwashing before leaving the room, and standard precautions for infection control. Orders and the TAR showed that PICC line dressings were to be changed weekly, and the MAR showed daily IV antibiotic administration. Surveyor observations on one morning showed that an LPN performed hand hygiene and donned two pairs of gloves along with other PPE before entering the resident’s room to obtain blood pressure and administer medications. The LPN entered the room multiple times, repeatedly double-gloving, and handled the blood pressure cuff, trash can lid, medication cart, and medication cards without performing hand hygiene between glove removal and donning new gloves. At one point, the LPN removed gloves, closed the trashcan lid with a gloved hand, then removed gloves and immediately donned a clean pair without hand hygiene before preparing and administering the resident’s oral medications. Later, when preparing to administer IV antibiotic through the PICC line, the LPN again donned PPE, placed supplies on paper towels on the overbed table, removed the cap from the PICC access port, and wiped the port with an alcohol pad for less than three seconds before flushing with normal saline. During this process, IV tubing touched the resident’s bedding, the access port fell back onto the resident’s arm, and the LPN discarded the contaminated tubing, obtained new tubing, and again wiped the access port for less than three seconds before attaching the tubing and starting the IV medication, without performing hand hygiene or changing gloves during the sequence. A subsequent observation the same day showed the treatment nurse at the bedside with the resident’s PICC line dressing removed, leaving the site uncovered while the resident looked at the open site and was not wearing a mask. The LPN entered without performing hand hygiene before donning PPE, administered oral medication, disconnected the IV tubing from the PICC line, wiped the access port for three seconds, and flushed with normal saline. The treatment nurse stated responsibility for PICC dressing changes and believed the last dressing change had occurred the prior week, but also reported that the dressing removed that day was marked with a date indicating it was due for change the previous day and that the dressing had not been changed because supplies had to be ordered. Facility records showed that the TAR had been signed for a PICC dressing change on a scheduled day, while later nursing documentation described that a dressing change ordered for a specific day had not been performed as ordered. Facility policies and CDC-based documents required hand hygiene before and after glove use, hand hygiene after glove removal, and disinfection of needleless access devices for at least 15 seconds, and the DON stated that the PICC port should be cleaned for 15 seconds and that the dressing should be in place before starting medication, which contrasted with the observed practices. Interviews with the LPN revealed that double gloving was used so gloves would not have to be changed as often, and the LPN acknowledged that hand hygiene should have been performed after removing gloves and before donning new ones. The LPN initially could not state the required length of time for scrubbing the PICC access port and later stated it should have been cleaned for at least 15 seconds, which differed from the observed practice of wiping for less than three seconds. The treatment nurse described limited availability of PICC dressing kits and that no specific person was responsible for ordering them, and reported having changed the resident’s PICC dressing two to three times since admission. The APN and DON both stated expectations that PICC sites and access ports be kept sterile or clean during medication administration and flushing, that staff use only one set of gloves at a time with handwashing between glove changes, and that the PICC port be cleaned for 15 seconds with alcohol swabs even when medicated caps are used. These expectations and policies contrasted with the observed failures in hand hygiene, glove use, PICC port disinfection, and maintaining an intact dressing prior to accessing the PICC line.
Inconsistent Documentation of DNR Status in Medical Record
Penalty
Summary
The facility failed to ensure that one resident’s medical record accurately and consistently reflected the resident’s advance directive specifying no Cardiopulmonary Resuscitation (CPR). The resident had non-Alzheimer’s dementia, anxiety, depression, moderate impairment in decision-making, and was receiving hospice services. Documentation in the record included a Durable Power of Attorney for Health Care, a Living Will Declaration, and a Resuscitate/Do Not Resuscitate order, all indicating that CPR and chest compressions were to be withheld and that the resident was a Do Not Resuscitate (DNR). The resident’s face sheet also indicated an advance directive for no CPR. Despite these documents, multiple parts of the electronic health record and physician documentation identified the resident as a full code. Physician’s orders from admission onward, including after the resident was admitted to hospice, contained orders indicating full code status. A MD progress note also documented the resident as a full code, and the Medication Administration Record (MAR) for the reviewed period listed the resident as full code. These entries conflicted with the existing DNR orders and advance directive documents in the record. Interviews with nursing staff and leadership confirmed awareness of the discrepancy between the resident’s documented advance directives and the active physician orders and MAR entries. A RN, an LPN, the ADON, the DON, and the Administrator each acknowledged that the resident’s advance directives and resuscitate/do not resuscitate order indicated DNR status, while the current physician orders and MAR showed full code. Staff stated that code status is typically verified using the medical record, MAR, and face sheet, and they recognized that the inconsistency meant staff could rely on incorrect information about whether to initiate CPR. Facility policy required that advanced directives be respected, that the plan of care be consistent with documented treatment preferences, and that the physician be notified so appropriate orders could be documented in the medical record and care plan, which did not occur in this case.
Failure to Revise Sexual Expression Care Plan After Cognitive Decline
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive care plan after a significant decline in cognitive status and changes documented on the quarterly MDS. One resident with active diagnoses of depression, insomnia, and non-Alzheimer’s dementia had a BIMS score of 09 on the 07/30/2025 quarterly MDS, indicating moderate cognitive impairment, which later declined to a BIMS score of 03 on the 01/05/2026 quarterly MDS, indicating severe cognitive impairment. Despite this documented decline, the resident’s care plan continued to include an active problem of “Sexual Expression,” initiated on 08/15/2025 after an incident in which the resident was found in another resident’s bed with both residents partially undressed and engaging in intimate behavior. The care plan goal was to allow the resident to engage in sexual behavior with other consenting residents, with interventions focused on ensuring appropriate consent, providing privacy, and observing for changes in mood or cognition. Interviews and record reviews showed that the care plan was not updated to reflect the resident’s current cognitive status or capacity for consent. The resident’s responsible party stated that the resident was not capable of consenting to sexual relationships or activity and had not been capable for a long time, and identified themselves as the decision maker. An LPN familiar with the resident reported that the resident could not express needs or wants and did not believe the resident was ever capable of making decisions about a sexual relationship, despite what was documented on the care plan. Another LPN stated that the current care plan was not accurate due to the resident’s steady decline. The Social Services Director reported completing sexual consent questionnaires for both involved residents at the time of the original incident and determining they could consent, but acknowledged the form was not set to repeat on subsequent assessments. The Medical Director stated that a care plan for sexual activity for a resident with a BIMS score of 03 was not appropriate because sexual knowledge would be low, and the Administrator confirmed that care plans were expected to be updated quickly when the MDS reflected a change, underscoring that this did not occur for this resident’s sexual expression care plan.
Failure to Update Care Plan for New Exit-Seeking Behaviors Leading to Elopement
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement an effective, updated comprehensive care plan with individualized interventions in response to new onset wandering, exit‑seeking, and elopement‑related behaviors for a resident on a secured unit. The resident had a history of traumatic brain injury, cerebral infarction (stroke), altered mental status, and was admitted to the secured unit due to traumatic brain injury and elopement risk. A quarterly MDS showed the resident was cognitively intact with a BIMS score of 12 and independent with ambulation, but a later BIMS showed a score of 2, indicating moderately impaired cognition. Despite these changes and the resident’s known elopement risk, the care plan initiated months earlier contained only general interventions such as therapeutic activities and medication monitoring, and no additional or revised interventions were added after 08/25/2025 to address later‑emerging behaviors or elopement attempts. On 01/13/2026, multiple progress notes documented significant behavioral changes and explicit exit‑seeking behavior. Early that morning, staff recorded that the resident was up all night walking the halls, refusing to go to bed, entering other residents’ rooms, and voicing that they did not live in the facility. The resident stated an intent to get out of the window. Later that day, another note documented that the resident had been seeking elopement since returning from a home visit, admitted a desire to leave, had been looking for ways to get out, and followed staff out locked doors, showing force when staff tried to return the resident to the unit. A further note that evening described the resident talking loudly, being aggressive toward staff, and again stating a desire to get out of the facility. Although an elopement assessment was completed at that time, there were no new care plan interventions put in place to guide staff in preventing exit‑seeking or managing the aggressive behaviors. In the weeks that followed, staff interviews and documentation showed that the resident continued to exhibit wandering and exit‑seeking behaviors without corresponding care plan revisions. Staff reported that after a family home visit, the resident began trying to leave the unit, walked door to door asking how to get out, watched staff to see if they were paying attention, and talked about leaving. On the night of the elopement, camera footage showed the resident repeatedly moving between the room, day room, and bathroom before entering the room and not re‑emerging. A CNA on duty stated that the resident had been going in and out of the room earlier in the shift, then went back to the room and was not checked on again; the CNA also reported dozing off during the shift and not hearing the window break. In the early morning hours, staff discovered the resident’s window busted and the resident missing, and a progress note documented that the resident had eloped by throwing an end table through the window. A police report and interviews confirmed that the resident was found off‑site after nearly being struck by a vehicle, having left the facility to find family. Throughout this period, the facility did not update the resident’s care plan with individualized, effective interventions to address the clearly documented new onset wandering, exit‑seeking, and elopement behaviors.
Removal Plan
- Revise Resident #1's care plan to include individualized elopement prevention interventions updated to include all interventions per the Plan of Removal.
- Complete new elopement risk assessments for residents residing on the secured unit.
- For any resident scoring moderate or high risk, review care plans to ensure individualized elopement interventions are present.
- Complete environment exit safety checks.
- Revise and update all secured unit residents' care plans based on the Plan of Removal.
- Provide in-service education to nursing and direct care staff on the elopement policy and missing resident procedures.
- Provide in-service education to nursing and direct care staff on the definition and examples of elopement and exit-seeking behaviors, early warning signs requiring interventions, and requirements to notify the nurse, administrator, or DON of new or increased behaviors.
- Provide in-service education to nurse management responsible for updating care plans on mandatory care plan revision following behavior changes with individualized interventions.
- Order shatter-resistant film for front-facing secured unit windows and install it.
- Implement monitoring for the DON or designee to review the 24-hour report to identify new or increasing exit-seeking behaviors.
- Implement monitoring for the DON or designee to complete audits to verify elopement risk assessments are completed, individualized interventions are present, and documentation reflects staff implementation, then transition to routine QAPI monitoring.
Elopement from locked unit due to inadequate supervision and response to exit-seeking behaviors
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain an environment free from accident hazards for a resident with known wandering and elopement risk, resulting in an elopement through a broken bedroom window. The resident had a history of traumatic brain injury, cerebral infarction, altered mental status, and wandering, and had been admitted to a secured unit due to elopement risk. An MDS assessment earlier in the year showed the resident as cognitively intact and independently ambulatory, but a later BIMS assessment showed moderately impaired cognition. The resident’s care plan identified the need for placement on a secured unit related to traumatic brain injury and elopement risk, with interventions focused on therapeutic activities and monitoring of psychotropic medications, but did not include enhanced supervision measures in response to escalating exit-seeking behaviors. In the weeks prior to the elopement, multiple progress notes and staff interviews documented increased exit-seeking and behavioral changes after the resident returned from a home visit. On one day, progress notes recorded that the resident was up all night walking the halls, going in and out of other residents’ rooms, voicing that they did not live in the facility, and stating an intention to get out through a window. Staff documented that the resident had been seeking elopement since returning from a home visit, had been looking for ways to get out, followed staff out locked doors, and showed force when staff tried to return the resident to the unit. Another note from the same day described the resident talking loudly, being aggressive toward staff, and repeatedly expressing a desire to leave the facility. An elopement assessment documented that the resident ambulated independently, had a history of following staff and others, and had been wandering halls and standing by locked exit doors after returning from home. On the night of the elopement, camera footage showed the resident repeatedly moving between the resident’s room, the day room, and the bathroom until entering the room at approximately 3:12 a.m. and not re-emerging. Staff interviews revealed that the CNA assigned to the unit acknowledged that the resident had been trying to start a fight with another resident for two days, that the resident typically went in and out of the room throughout the night, and that staff did not normally go back to check on the resident once the resident returned to the room. The CNA reported that she did not check on the resident after the last interaction around 9:30–10:00 p.m., that she sometimes could not take breaks due to staffing, and that she dozed off for about 30 minutes during the shift. The DON later stated that the CNA reported falling asleep and not hearing the window break. Staff discovered the broken window only when an LPN returned from break around 4:25 a.m., at which point the resident was found to be missing. Law enforcement records and interviews confirmed that the facility reported the resident missing in the early morning hours and that the resident was located off-site by police after a citizen reported almost striking the resident with a vehicle. The police officer stated that the resident was found near a school approximately 1.9 miles from the facility, requiring travel across an intersection and along areas without sidewalks. The resident told police they were walking to find family. Interviews with multiple CNAs and nurses indicated that the resident had been going door to door asking how to get out, watching staff to see if they were paying attention, and walking back and forth to doors after returning from a family visit. The DON and Administrator both stated they were not aware of prior elopement attempts beyond wandering and walking back and forth, and the MDS Coordinator reported she had not been informed of the January incident in which the resident voiced a plan to escape through a window. Facility policies required staff to know the location of residents under their care and to implement care plan strategies for residents at risk of wandering or elopement, but staff interviews showed that routine checks were not performed on the resident during the night of the incident and that the resident’s escalating exit-seeking behaviors were not effectively communicated or translated into increased supervision. A police incident report and witness statements further detailed that the resident exited the building by throwing an end table through the bedroom window. The facility’s own missing resident and wandering/elopement policies stated that staff are responsible for knowing residents’ whereabouts and that care plans for at-risk residents must include safety strategies and interventions. Despite documented behaviors such as wandering, standing at locked doors, following staff out locked exits, verbalizing intent to leave, and specifically stating a plan to get out through a window, there was no evidence in the record that supervision was increased or that staff adjusted monitoring practices during periods of heightened exit-seeking. Staff interviews also revealed that for several weeks there had often been only one CNA on the locked unit at night, and that the CNA on duty the night of the elopement positioned herself in a doorway with hall lights off and later admitted to dozing off. These actions and inactions resulted in the resident being able to break the window, leave the secured unit and facility, and travel a significant distance off-site before being located and returned by police.
Failure to Follow Care-Planned Assistance and Supervision Leading to Resident Falls
Penalty
Summary
Facility staff failed to follow care-planned interventions for assistance and supervision for two residents, resulting in falls. Resident #2, admitted with Alzheimer's disease, spastic hemiplegic cerebral palsy, and neuromuscular bladder dysfunction, had a care plan requiring assistance of two staff for bathing/showering, bed mobility, personal hygiene, toilet use, and transferring. On 06/04/2025, the DON and an LPN responded to Resident #2's room and found the resident on their back on the floor after CNA #1 attempted to perform incontinent care alone, contrary to the care plan specifying a two-person assist for bed mobility, transfers, and personal hygiene. CNA #1 later stated that, upon hiring, it was not made clear how to access the electronic care plan system and that initial training on the system was brief and difficult to see. Resident #3 was admitted with spinal stenosis of the cervical region, cervical disc disorder with radiculopathy, generalized muscle weakness, and was receiving surgical aftercare following nervous system surgery. The care plan required assistance of one staff member for toileting, bathing/showering, dressing, and bed mobility, and assistance of two staff members for transferring, including use of a sliding board with two-person assist. A progress note documented that on 01/15/2026, an LPN was called to Resident #3's room and found the resident lying face down on the floor wearing a cervical collar, after the resident reported being told to dress themself. The resident later recounted that a CNA had helped them to a seated position at the edge of the bed, then left the room with another staff member while the resident attempted to dress themself, during which time the fall occurred. Interviews with multiple CNAs and facility leadership confirmed that CNAs were expected to obtain resident care instructions from the electronic care plan/Kardex system and that Resident #3 required staff assistance for all tasks except meals. CNA #2 acknowledged leaving Resident #3 unattended while assisting another staff member, despite the electronic care plan indicating the resident did not perform tasks alone. Another CNA reported sometimes being the only staff member in the room when transferring Resident #3 with a slide board, even though the care plan required two staff. The DON and Administrator stated that aides were trained one-on-one on the electronic care plans after morning huddles and that CNAs were expected to verify care requirements in the electronic care plan before providing care. The Medical Director stated it was his expectation that orders were followed as written in the care plan. Standard of practice cited requires that residents receive treatment and care in accordance with professional standards, the comprehensive person-centered care plan, and residents' choices.
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