Conway Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Conway, Arkansas.
- Location
- 2603 Dave Ward Drive, Conway, Arkansas 72034
- CMS Provider Number
- 045245
- Inspections on file
- 33
- Latest survey
- August 21, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Conway Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
A resident who was cognitively intact and admitted for anxiety disorder was discharged to another facility despite having filed an appeal against the involuntary discharge. Staff and the Medical Director reported no evidence of physical abuse or smoking policy violations by the resident. The Ombudsman and the resident's family confirmed the appeal was filed before the discharge, but the facility proceeded with the transfer in violation of policy requiring appeals to be resolved prior to discharge.
The facility failed to maintain a safe and homelike environment, with observations of cluttered floors, detached wall vinyl, and wall rails posing potential hazards. Maintenance was unavailable, and no requests for repairs were documented, indicating a lack of proactive measures to address these issues.
The facility failed to prevent continuous verbal and physical altercations between two residents, despite multiple incidents and staff interventions. These altercations caused distress among other residents and posed a serious risk of harm, leading to a determination of non-compliance with federal regulations.
The facility failed to ensure interventions were utilized to prevent worsening of contractures for two residents. One resident did not have a left elbow extension brace or cushion boots as required, and another resident did not have a hand brace in place, leading to worsening contractures. Both a CNA and an RN confirmed that the absence of these interventions could lead to further complications.
The facility failed to maintain sanitary conditions and properly clean food preparation equipment and utensils in the kitchen. Observations included expired food items, unsanitary surfaces, and improper cleaning of a food processor used to prepare food for residents. Kitchen utensils were also stored in a manner that exposed them to contaminants.
The facility failed to ensure proper hand hygiene by laundry staff between resident rooms while delivering clean laundry and did not keep a trash barrel covered, allowing a resident with severe cognitive impairment to dig through the trash. Staff interviews revealed a lack of adherence to infection control policies and delayed action in addressing the need for a trash barrel lid.
The facility failed to provide pneumonia vaccines to two residents despite having obtained their consent. The current process involves Social Services obtaining consent and uploading it into the chart, but there is a lack of clarity on who ensures the orders are completed, leading to the deficiency.
A resident with severe cognitive impairment and multiple diagnoses was found unable to reach their call light due to improper placement and a fall mat blocking access. The care plan required the call light to be within reach, but this was not adhered to, as confirmed by a CNA.
The facility failed to update the care plan for a resident with severe cognitive impairment and aggressive behaviors. Despite a care plan revision indicating placement on a secured unit, the resident was returned to a regular room after family opposition. The Administrator was unaware of issues with the resident's vulnerable roommate, and the MDS Coordinator stressed the importance of an accurate care plan for quality care.
The facility failed to ensure that a resident was free from unnecessary psychotropic medication. The resident, with severe cognitive impairment and multiple diagnoses, was prescribed Depakote and Quetiapine without appropriate clinical indications or implementation of gradual dose reductions (GDR) and non-pharmacological interventions. Interviews revealed a lack of understanding of the medications' appropriate use and regulatory requirements.
Resident Discharged Despite Pending Appeal
Penalty
Summary
The facility failed to comply with regulations regarding the discharge of a resident who had filed an appeal against an involuntary discharge. The resident, who was cognitively intact and admitted with an anxiety disorder, was issued a 30-day discharge notice. Despite the resident filing an appeal on the same day the notice was given, the facility proceeded to discharge the resident to another facility the following day. The care plan for the resident did not indicate any anticipated discharge, and there was no documentation of smoking behavior or physical abuse by the resident. Multiple staff members, including CNAs and the Medical Director, reported no knowledge or evidence of the resident being physically abusive or violating smoking policies. Interviews with the resident, their family member, and the Ombudsman confirmed that the resident did not want to be discharged and had filed an appeal prior to being removed from the facility. The Ombudsman stated that the appeal was cancelled only after the resident had already been discharged. Facility policy and federal regulations prohibit the transfer or discharge of a resident while an appeal is pending, unless there is a documented risk to health or safety, which was not substantiated in this case. The Administrator acknowledged awareness of the pending appeal but chose to proceed with the discharge regardless.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe and homelike environment, as evidenced by several observations during environmental rounds. In one room, clutter was observed on the floor, including cardboard boxes, shoes, clothes, personal documents, books, magazines, and plastic grocery bags of clothes, which were spread out between and in front of the privacy curtain. Additionally, a bedside table obstructed the sink pathway, with detached cords lying on the floor. In the dining room, wall vinyl was detaching, and the floor had discolored stains and debris. Another room had a wall rail detached from the wall, held up by a bedside table, and vinyl trim was detached from the wall with gashes present, exposing a grainy white substance. During a tour with the Administrator and the Corporate Nurse Consultant, it was revealed that maintenance was not available, and there were no maintenance requests for the observed issues in the facility's Maintenance Request Book. The Administrator acknowledged the absence of maintenance, and the Corporate Nurse Consultant stated that repairs would be made immediately. However, the lack of documented maintenance requests indicates a failure to address environmental hazards proactively, contributing to the unsafe conditions observed.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure residents were free from abuse, resulting in continuous altercations of verbal and physical abuse between two residents. Resident #47, who has diagnoses including cerebral palsy, bipolar disorder, and PTSD, and Resident #54, who has Down Syndrome and generalized anxiety disorder, were involved in multiple incidents. These altercations included verbal threats and physical aggression, such as kicking and ramming wheelchairs, which were witnessed by other residents and staff. Despite previous incidents and attempts to separate the residents, the facility did not effectively prevent further altercations, leading to a significant risk of harm to all residents in the facility. On multiple occasions, staff observed and intervened in altercations between Resident #47 and Resident #54. For example, on one occasion, Resident #54 rammed their wheelchair into Resident #47, leading to a heated argument and physical aggression. Staff attempted to separate and calm the residents, but the altercations continued to occur. Witnesses, including other residents and staff members, reported that these incidents were frequent and disruptive, causing distress among other residents. Despite these observations, the facility's interventions were insufficient to prevent further incidents. Interviews with staff and residents revealed that the altercations between Resident #47 and Resident #54 were a common occurrence, with some residents expressing feelings of unsafety and disturbance. Staff members reported that they tried to keep the residents apart and monitored them, but these measures were not effective in preventing the altercations. The facility's failure to implement effective interventions and protect residents from abuse led to a determination of non-compliance with federal regulations, posing a serious risk of harm to the residents.
Removal Plan
- Resident #47 was placed on 1 on 1 observation by nursing staff for verbal altercation that occurred in the dining room.
- Resident #54 was placed on 1 on 1 observation by nursing staff for verbal altercation that occurred in the dining room.
- Resident #47 was transported to [local hospital] for medical clearance to be evaluated and treated for behavioral health.
- Nurse consultant in-serviced Administrator, Assistant Administrator, and the Assistant Director of Nursing (ADON) on ensuring any resident-to-resident altercation and any residents that witness the altercation are assessed for psychosocial affects and offered Mental Health Services if needed.
- Assistant Administrator in-serviced all staff on duty on Resident-to-Resident altercations, to stop the altercation immediately, and protect the resident involved. This includes any resident that witnessed the altercation to ensure an assessment is completed to ensure their psychosocial wellbeing is addressed and any Mental Health issues are assessed. Assistant administrator will in-service all oncoming employees before starting assigned shifts.
- Assistant Administrator interviewed all residents that are interviewable for any psychosocial distress and offered mental health care as needed.
- Nurse consultant contacted our behavioral health provider to immediately see any residents that have been negatively affected and were available as needed. Mental Health services provider was notified.
Failure to Prevent Worsening of Contractures
Penalty
Summary
The facility failed to ensure interventions were utilized to prevent worsening of contractures for two residents. Resident #40 had diagnoses of abnormal posture, stiffness of the left shoulder, and stiffness of the left elbow. The care plan indicated the resident required a restorative program to maintain range of motion and prevent contractures, including the use of a left elbow extension brace and cushion boots. However, observations on multiple occasions revealed that these interventions were not in place. Both a CNA and an RN confirmed that the absence of these interventions could lead to worsening contractures and the development of pressure ulcers. Additionally, the resident's care plan was not being followed as prescribed, leading to potential harm to the resident's condition. Resident #66 had a diagnosis of hemiplegia and hemiparesis after a cerebral vascular incident and required a hand brace for at least 16 hours a day. Despite this, observations showed that the resident did not have the hand brace in place, and the contracture had worsened. The CNA mentioned that the resident could not handle the brace anymore and inserted a washcloth in the resident's hand as an alternative. The RN was unaware of the specific interventions in place for the resident's contracture, indicating a lack of proper communication and adherence to the care plan. The absence of necessary interventions led to the worsening of the resident's condition, highlighting a significant deficiency in the facility's care practices.
Unsanitary Conditions and Improper Cleaning Practices in Kitchen
Penalty
Summary
The facility failed to ensure that dishes and utensils were stored under sanitary conditions and that food preparation equipment was cleaned properly in the kitchen. Observations by the surveyor revealed multiple instances of unsanitary conditions, including a hand washing station with water leaking from the base, creating a red-brown stain, and an eye wash station covered in red/brown spots with debris inside. Expired food items, such as tortillas, were found in storage, and various kitchen surfaces, including the backsplash and surveillance camera, were covered in yellow/brown and brownish-gray material, respectively. Additionally, a medium-sized hole was observed in the ceiling, and fans in the kitchen were coated in gray/black matter. The venti hood and surrounding areas were also found to be covered in yellow/brown matter, with a nozzle dripping off the orange rubber piece and a white plastic pipe thickly coated in the same substance. The dishwashing area had discolored tiles, missing tiles, and a large crack in the back wall, with a red/brown stain on one of the tiles and a hole in the middle of it. The back wall of the three-compartment sink was discolored, and a faucet was continuously dripping. The food processor was observed to have soap bubbles and water inside after being run through the dishwasher, and it was used to prepare food for residents without being properly cleaned. Kitchen utensils were stored in a manner that exposed them to contaminants, and a dietary aide was observed touching the inside of a scoop before using it to prepare food for residents on pureed diets. The dietary manager confirmed that the cleaning schedule was the only one in use, and it was evident that the schedule was not being followed adequately. The surveyor observed multiple instances of unsanitary conditions and improper cleaning practices, which were confirmed by the dietary manager and dietary aide. The facility's failure to maintain sanitary conditions and properly clean food preparation equipment and utensils posed a risk to the health and safety of the residents. The observations made by the surveyor highlighted significant deficiencies in the facility's adherence to professional standards for food storage, preparation, and distribution.
Infection Control and Trash Barrel Coverage Deficiencies
Penalty
Summary
The facility failed to ensure proper hand hygiene was performed by laundry staff between resident rooms while delivering clean laundry. During an observation, a laundry employee was seen coughing into her hands and then handling clean laundry without sanitizing her hands. This practice was repeated as the employee moved from one resident room to another, delivering laundry and collecting empty hangers without performing hand hygiene. Interviews with the laundry staff revealed a lack of awareness and adherence to the facility's infection control policies, which require hand sanitization before and after entering resident rooms. Additionally, the facility failed to keep a trash barrel covered, which allowed a resident with severe cognitive impairment to dig through the trash. The resident was observed moving garbage around and lifting items from the barrel, which was located in a common area without a lid. Interviews with staff indicated that there was awareness of the need for a lid on the trash barrel, but it had not been promptly addressed. The Assistant Director of Nursing and the Administrator confirmed that trash barrels should be covered to prevent infection and resident access, and that lids had been recently ordered but not yet implemented.
Failure to Administer Pneumonia Vaccines
Penalty
Summary
The facility failed to provide a pneumonia vaccine for two residents, despite having obtained their consent. The facility's policy specified that each resident should be assessed for pneumococcal immunization upon admission and offered the vaccine unless medically contraindicated or already immunized. However, a review of the electronic health records for both residents showed no information indicating that the pneumonia vaccine was administered, even though consent forms were signed and dated for both residents. The Infection Control Preventionist (IPC) confirmed that the vaccines were never administered and mentioned that the facility was working on a process for vaccine notifications. During interviews, it was revealed that the current process involves Social Services obtaining consent from new residents and uploading the document into their chart. The nurse is then supposed to check the computer for the document and order the vaccine. However, Social Services was not aware of who ensures that the orders are actually completed. This lack of clarity and communication led to the failure in administering the pneumococcal vaccines to the two residents.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call device was within reach, which is a critical aspect of accommodating the needs and preferences of residents. Resident #29, who has severe cognitive impairment and multiple diagnoses including Parkinson's Disease, Type 2 diabetes, and a history of repeated falls, was observed sitting in a wheelchair in the middle of the room with the call light lying across the bed on top of the linens. The resident was unable to reach the call light due to a fall mat impeding access to the bed. This situation was confirmed during an interview with CNA #2, who acknowledged that the call light should have been within reach and moved the resident's wheelchair closer to the bed to rectify the situation. The resident's care plan, which was initiated on 06/01/2020, specifically included an approach to ensure the call light was within reach to mitigate the risk of falls and serious injury. Despite this, the call light was not accessible to Resident #29 at the time of the surveyor's observation. The CNA's statement and subsequent actions confirmed the deficiency, highlighting a lapse in adhering to the care plan and ensuring the resident's safety and ability to call for assistance when needed.
Failure to Update Care Plan for Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to update the care plan for a resident with severe cognitive impairment, Down Syndrome, Generalized Anxiety Disorder, and Unspecified Intellectual Disabilities. The resident exhibited disruptive and aggressive behaviors, including yelling at other residents and staff, throwing items, and physically aggressing towards others. Despite a care plan revision indicating the resident was placed on a male secured unit to decrease stimuli, the resident was later returned to a regular room on the 400 hall after a care plan conference where the family opposed the suggested placement. The facility did not update the care plan to reflect these changes accurately. The Administrator acknowledged that the resident was moved to see if a decrease in stimuli would help but was returned to the original hall after being hit. The Administrator was unaware of any issues with the resident's vulnerable, non-verbal, and fully dependent roommate, despite the resident's aggressive behavior towards them. The MDS Coordinator emphasized the importance of an accurate care plan for providing the best quality of care, noting that inaccuracies could result in unmet needs for the resident.
Failure to Ensure Residents Are Free from Unnecessary Psychotropic Medication
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary psychotropic medication, specifically for one resident who was prescribed Depakote and Quetiapine. Resident #51, who had Alzheimer's disease with late onset, unspecified dementia, depression, PTSD, and unspecified convulsions, was receiving Depakote for seizures and behaviors and Quetiapine for PTSD. The physician orders for these medications did not include an end date, and the clinical indications for their use were not aligned with the FDA-approved indications for these drugs. Interviews with the LPN and ADON revealed a lack of understanding of the appropriate clinical indications for these medications and the process for addressing unnecessary medications with the physician, including the use of gradual dose reductions (GDR). The facility did not implement GDR or non-pharmacological interventions prior to or instead of continuing the psychotropic medications, as required by regulations. The quarterly Minimum Data Set (MDS) assessment indicated that Resident #51 had severe cognitive impairment and exhibited behavioral symptoms 1 to 3 days a week. Despite this, the facility did not adequately address the necessity of the psychotropic medications. The LPN and ADON both acknowledged that the resident was receiving these medications for behaviors and mood stabilization, but they did not demonstrate a clear understanding of the appropriate use of these medications or the regulatory requirements for GDR and non-pharmacological interventions. This deficiency highlights a failure in the facility's medication management practices and oversight by the interdisciplinary team (IDT).
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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