Innisfree Health And Rehab, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Rogers, Arkansas.
- Location
- 301 South 24th Street, Rogers, Arkansas 72758
- CMS Provider Number
- 045302
- Inspections on file
- 18
- Latest survey
- November 15, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Innisfree Health And Rehab, Llc during CMS and state inspections, most recent first.
The facility did not make the survey results easily accessible to residents, family members, and legal representatives. The survey book was placed at the back of the greeting desk, requiring residents to ask for assistance to view it. Staff interviews confirmed the book's location and the need for residents to request access, which the Administrator acknowledged as incorrect.
A facility failed to update a care plan for a resident with contracture management needs. The resident, with severe cognitive impairment and functional limitations, did not have a restorative program or functional maintenance plan included in their care plan. Observations showed the resident was not using a required hand roll, and there was no documentation of its use. The DON confirmed the lack of a comprehensive care plan, and the part-time LTC MDS coordinator was unavailable for guidance.
The facility failed to remove expired tube feeding and properly label insulin vials and inhalers with open dates, as observed in the medication room and carts. An LPN acknowledged the expired items needed disposal, and the DON was unaware of improper labeling practices, indicating a lapse in adherence to medication storage policies.
The facility failed to prepare pureed meals with the appropriate consistency, resulting in thick and unappetizing food for residents, including one with dysphagia. Dietary staff did not add sufficient liquid to pureed meals, leading to difficulties in consumption. The issue was confirmed by dietary staff and a speech therapist, who noted that the meals did not meet the required consistency standards.
The facility exhibited deficiencies in food handling and storage practices. Dietary staff failed to change gloves and wash hands after handling contaminated items, leading to potential food contamination. Additionally, food items in the refrigerator and freezer were not properly covered, sealed, or dated, and expired items were not discarded. The Activities Director confirmed that food storage protocols were not followed, compromising food safety.
The facility failed to properly store and manage oxygen and CPAP equipment for two residents, leading to deficiencies in infection prevention and control. A resident with severe cognitive impairment had oxygen tubing improperly stored, and another resident with Alzheimer's disease had CPAP equipment left unbagged. The facility lacked proper care plans and documentation for equipment maintenance, as confirmed by the DON and an LPN.
The facility failed to ensure residents had access to a functioning call system, affecting four residents with various impairments. Observations showed call lights were out of reach, and staff confirmed the absence of a policy for ensuring accessibility. This deficiency was identified through observations, record reviews, and staff interviews.
A facility failed to provide a written bed hold notice for a resident who was hospitalized, as required by their policy. The resident, who was cognitively intact, was transferred to the emergency room for altered mental status. The Business Office Manager contacted the resident's spouse, who was unsure if the resident would return, but no bed hold agreement was issued, resulting in non-compliance with the facility's policy.
A facility failed to include oxygen therapy in the care plan for a resident with shortness of breath, despite having an order for oxygen and an oxygen tank in the resident's room. The MDS Coordinators were unaware of the omission, and the facility lacked a policy on care plans.
A resident with severe cognitive impairment and musculoskeletal issues did not receive a prescribed hand roll for contracture management. Despite the care plan indicating the need for this device, observations and staff interviews confirmed its absence. The care plan lacked necessary restorative and functional maintenance programs, and the DON acknowledged the absence of a contracture management policy.
A resident was prescribed a PRN anti-anxiety medication for 45 days without proper justification or evaluation by a doctor. The Physician Assistant noted that the order was made by hospice, and there was no documented rationale in the clinical records. The DON stated that PRN medications should be limited to 14 days unless justified, and the facility lacked a policy for PRN medication.
A resident with coordination and mobility issues was not provided with a necessary plate guard during meals, despite it being indicated in their care plan. Staff interviews confirmed the lack of consistent provision of adaptive equipment, and the facility lacked a policy on adaptive equipment.
A facility failed to send home health referrals before a resident's discharge, resulting in delayed care. The resident, with a history of mobility issues and other conditions, was discharged with orders for PT, OT, nursing, and CNA services. However, the referral was sent two days post-discharge, delaying the start of home health services. The facility lacked a discharge policy, and the SSD did not keep fax confirmations, leading to a lapse in the discharge process.
Survey Results Accessibility Deficiency
Penalty
Summary
The facility failed to make the results of the most recent survey readily accessible to residents, family members, and legal representatives. Observations conducted over several days revealed that the survey book was located on the far back right-hand side of the greeting desk, making it difficult for residents, especially those in wheelchairs, to access without assistance. The survey book was not available in common areas such as the dining room, day room, or hallways, and residents were only seen near the greeting desk when accompanied by staff. Interviews with facility staff, including the receptionist, LPN, CNA Consultant, and the Director of Nursing, confirmed that the survey book was not easily accessible. The receptionist stated that the survey book was kept at the main entrance desk and that residents had to ask for it, often remaining at the desk to view it. The Administrator acknowledged that residents should not have to request the survey book and confirmed that the current practice was incorrect.
Failure to Update Care Plan for Contracture Management
Penalty
Summary
The facility failed to update the care plan for a resident with contracture and contracture management needs. The resident, who was admitted with diagnoses including dementia, muscle wasting, atrophy, and hemiplegia, had a severe cognitive impairment and functional limitations in range of motion. Despite these conditions, the care plan did not include a restorative program or a functional maintenance plan (FMP) that the resident was participating in. Additionally, there was no mention of a hand roll or device to prevent the worsening of the left-hand contracture, which was noted in the resident's closet care plan. Observations and interviews revealed that the resident was not using a hand roll, as required by the closet care plan, and there was no documentation of its use. The LTC MDS coordinator confirmed the resident's participation in a restorative program but acknowledged the absence of recommendations for a splint or brace following a therapy evaluation. The Director of Nursing (DON) confirmed the lack of documentation regarding the hand roll and the absence of a comprehensive care plan addressing the resident's needs. The LTC MDS coordinator, who works part-time, was not available to provide guidance on the development and completion of the MDS and care plan.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to adhere to proper medication storage and labeling protocols, resulting in expired and unlabeled medications being present in the medication room and carts. During an observation of the Long Term Care medication room, two bottles of tube feeding were found to be expired, yet still in current stock. The Licensed Practical Nurse (LPN) responsible for the area acknowledged that these bottles needed to be discarded. Additionally, during inspections of two medication carts, it was discovered that two insulin vials and three inhalers were not labeled with open dates, contrary to the facility's policy which requires dating when the manufacturer's seal is broken. The Director of Nursing (DON) was unaware that the nursing staff was labeling the bags instead of the insulin vials, which could lead to the loss of open date information if the bags were damaged or misplaced. The DON also believed that expiration date checks were conducted weekly, as assigned to LPN #5, but this was evidently not the case. These oversights in medication management highlight a lapse in adherence to the facility's medication storage policy, potentially compromising the safety and efficacy of the medications administered to residents.
Inadequate Consistency in Pureed Meals
Penalty
Summary
The facility failed to ensure that meals were prepared in a manner that maintained an acceptable appearance and consistency for residents, particularly those on pureed diets. During observations, it was noted that the dietary staff did not add sufficient liquid to pureed meals, resulting in a thick and unappetizing consistency. For instance, the egg sausage bake was pureed without adding broth or any liquid, leading to a thick consistency both before and after cooking. Similarly, pureed biscuits and hash browns were also prepared with inadequate liquid, resulting in a sticky and thick texture. Resident #42, who has dysphagia following a cerebral infarction and requires a pureed diet with honey consistency, was unable to consume the meals due to their thickness. The resident reported difficulty eating the pureed pancake served at breakfast, describing it as too hard to cut and eat. The Assistant Dietary Manager and Dietary Aide confirmed that the pureed foods served were too thick and acknowledged the need for more liquid to achieve the appropriate consistency. The speech therapist also confirmed that pureed diets should resemble pudding or mashed potato consistency, indicating that the meals served did not meet these standards.
Deficiencies in Food Handling and Storage Practices
Penalty
Summary
The facility failed to ensure proper food handling and storage practices, leading to multiple deficiencies. Dietary staff were observed not changing gloves or washing hands after handling contaminated items before touching food, which resulted in potential contamination of food served to residents. Specifically, a dietary staff member used gloves to handle a spray bottle and then directly handled food without changing gloves or washing hands. Another staff member was observed handling meal trays and beverages without washing hands after touching dirty objects. These actions were contrary to the facility's handwashing policy, which emphasizes the importance of hand hygiene in preventing contamination. Additionally, the facility did not adhere to proper food storage protocols. Observations revealed that food items in the refrigerator and freezer were not covered, sealed, or dated, and expired food items were not promptly discarded. Opened boxes of various food items, such as breaded pork patties, turkey burgers, and pie dough, were found unsealed in the freezer. Similarly, opened bags of food items in the emergency food supply and the Activities Room lacked proper sealing and open dates. The Activities Director confirmed that the food storage process was not followed, as items were not dated or sealed as required, compromising food safety.
Deficiencies in Infection Control for Oxygen and CPAP Equipment
Penalty
Summary
The facility failed to properly store and manage oxygen and CPAP equipment for two residents, leading to deficiencies in infection prevention and control. Resident #13, who had severe cognitive impairment and was on oxygen therapy for conditions including COPD, had oxygen tubing lying on the bed with the concentrator running while the resident was not present. There was no documented order for regular oxygen tubing changes to prevent infection, and the Medication Administration Record did not reflect consistent oxygen therapy administration. Additionally, the resident's progress notes indicated non-compliance with using the nasal cannula. Resident #52, diagnosed with Alzheimer's disease and obstructive sleep apnea, had a CPAP nasal pillow and tubing that were not properly stored, as they were found lying directly on the nightstand without a protective bag. The facility lacked a care plan for the CPAP use and maintenance, and there were omissions in the task of cleaning the CPAP equipment as documented in the Treatment Administration Record. Interviews with the DON and LPN #7 confirmed the lack of proper storage and cleaning procedures for both residents' equipment, highlighting a gap in the facility's infection control practices.
Inaccessible Call Light System for Residents
Penalty
Summary
The facility failed to ensure that residents had access to a functioning call system to request staff assistance, affecting four residents. Observations revealed that the call lights were not within reach for these residents, who had various impairments and required assistance for daily activities. For instance, one resident with communication difficulties and mobility impairments was observed with the call light cord on the floor, out of reach, and not clipped to the bed covers. Another resident, who required total staff assistance for mobility and personal hygiene, was found with the call light on the floor and requested help to place it within reach. Further observations showed that a resident with severe cognitive impairment and dependency on staff for mobility had the call light positioned behind the bed mattress, making it inaccessible. Similarly, another resident with multiple diagnoses, including dementia and arthritis, had the call light cord draped over the bed's metal piece, rendering it unreachable. These observations were confirmed by staff, who acknowledged that the call lights should be clipped to the bed covers or placed within reach to allow residents to call for assistance when needed. The facility lacked a policy or procedure for ensuring call lights were accessible to residents. The Director of Nursing and other staff confirmed the necessity of having call lights within reach and acknowledged the absence of a formal policy. The facility's failure to provide a working call system directly accessible to residents was identified through observations, record reviews, and staff interviews, highlighting a significant deficiency in ensuring resident safety and communication needs.
Failure to Provide Written Bed Hold Notice for Hospitalized Resident
Penalty
Summary
The facility failed to provide a written bed hold notice for a resident who was hospitalized, as required by their policy. The policy, revised in 2016, mandates that a bed hold policy be sent with the resident to the hospital and that the resident or their representative be contacted the next business day to determine if they wish to hold the bed. This should be documented on a bed hold form, which requires two signatures if contact is made by phone. However, in this case, the Business Office Manager (BOM) did not issue a bed hold agreement for the resident when they were transferred to the emergency room due to altered mental status. The resident involved was cognitively intact, as indicated by a Brief Interview of Mental Status (BIMS) score of 15, and was their own representative, although a spouse was listed as next of kin. The resident was admitted for skilled nursing care and later transferred to the emergency room. The BOM contacted the resident's spouse, who was unsure if the resident would return and stated they would notify the BOM by the following Monday. Despite this communication, no bed hold agreement was issued, resulting in a failure to comply with the facility's policy.
Oxygen Therapy Not Included in Care Plan
Penalty
Summary
The facility failed to ensure that oxygen therapy was included in the care plan for a resident diagnosed with shortness of breath. The resident had an order for oxygen therapy, prescribed as needed, and was observed to have an oxygen tank in their room. Despite this, the care plan did not reflect the resident's need for oxygen. Interviews with the Long Term Care MDS Coordinator and the Skilled MDS Coordinator revealed that they were unaware of why the oxygen therapy was not included in the care plan. Additionally, the facility administrator acknowledged that there was no existing policy on care plans.
Failure to Provide Contracture Management Device
Penalty
Summary
The facility failed to provide appropriate contracture management for a resident with severe cognitive impairment and musculoskeletal issues, including hemiplegia and contractures in the left hand and arm. Despite the resident's care plan indicating the need for a hand roll to prevent worsening of the contracture, no such device was provided. Observations revealed that the resident did not have a hand roll in place during activities or while in bed, and staff interviews confirmed the absence of the device. The resident's care plan, initiated after consultation with the LTC MDS Coordinator, did not include the necessary restorative program or functional maintenance plan. Interviews with facility staff, including a CNA and the DON, confirmed the lack of documentation and implementation of the hand roll for the resident's left hand. The DON acknowledged the absence of a policy for contracture management and was unsure of the guidance used by the LTC MDS Coordinator to develop the care plan. The LTC MDS Coordinator, who works part-time, was not available to provide further clarification. This oversight resulted in the resident not receiving the prescribed contracture management device, as outlined in their care plan.
Failure to Justify Extended PRN Anti-Anxiety Medication Order
Penalty
Summary
The facility failed to ensure that a resident did not have an order to receive a PRN anti-anxiety medication past 14 days without proper justification and evaluation by a doctor. The resident, who was cognitively intact with a BIMS score of 14, had an order for an anti-anxiety tablet to be administered every 2 hours as needed for anxiety related to an anxiety disorder for 45 days. However, there was no documented rationale for this PRN medication in the clinical records. Interviews revealed that the Physician Assistant did not order the medication and indicated that it was ordered by hospice, requiring her to put the order in her name. The Nurse Consultant confirmed the absence of information regarding the rationale for the medication order in the system. The Director of Nursing stated that PRN anti-anxiety medication should be ordered for only 14 days, and if ordered for more than 14 days, a documented rationale should be present in the clinical record. Additionally, the facility lacked a policy for PRN medication.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide necessary adaptive eating equipment for a resident who required it, leading to a deficiency. The resident, who had a diagnosis of unspecified lack of coordination, Parkinsonism, hemiplegia, and hemiparesis, was cognitively intact and required partial assistance with meals. The resident's care plan and tray card both indicated the need for a plate guard during meals. However, observations on multiple occasions revealed that the resident was not provided with a plate guard, and the resident expressed that there was only one section plate available in the building. Interviews with staff, including the Assistant Dietary Manager and a Certified Nurse Assistant, confirmed that the resident was not consistently provided with the necessary adaptive equipment, such as a plate guard. The Rehabilitation Director was informed of the resident's difficulties with spilling food but was unsure if an evaluation had been conducted. Additionally, the Director of Nursing stated that the facility did not have a policy on adaptive equipment, further contributing to the oversight in providing the required equipment for the resident.
Failure to Timely Send Home Health Referrals
Penalty
Summary
The facility failed to send home health referrals prior to the discharge of a resident, leading to a delay in the initiation of necessary home health services. The resident, who was cognitively intact and had a history of right femur fracture, muscle weakness, and other conditions, was discharged with orders for physical therapy, occupational therapy, nursing, and CNA services. However, the facility did not have a policy for the discharge process, and the Social Services Director (SSD) could not provide proof of when the referral was faxed, as no fax confirmations were kept. The home health agency confirmed receiving the referral two days after the resident's discharge, resulting in a delay in care. The resident's family reported that home health services did not start until four days post-discharge, and the resident sought medical treatment at a hospital shortly thereafter. The facility's Administrator acknowledged that referrals should not be sent after discharge, indicating a lapse in the discharge planning 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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