Jamestown Nursing And Rehab, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Rogers, Arkansas.
- Location
- 2001 Hampton Place, Rogers, Arkansas 72758
- CMS Provider Number
- 045435
- Inspections on file
- 27
- Latest survey
- May 22, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Jamestown Nursing And Rehab, Llc during CMS and state inspections, most recent first.
A resident with a history of morbid obesity, mood disorder, and chronic pain, who was admitted with a stage IV pressure ulcer, consistently refused care, including wound care and personal hygiene. The facility failed to implement and modify care interventions to meet the resident's needs, resulting in severe neglect and the presence of maggots in the wound. The lack of specific policies for wound care and urinary catheters, along with inadequate execution of the care plan, contributed to the resident's decline and eventual death.
A resident with a history of chronic pain and anxiety was admitted with a stage 4 pressure ulcer and refused care due to pain. The facility failed to offer effective interventions such as surgical interventions under anesthesia, intravenous pain medication, or anti-anxiety medication. The Medical Director was not involved, and the Administrator did not participate in resident communications. The lack of effective communication and coordination among staff contributed to the deficiency, resulting in Immediate Jeopardy.
A facility failed to provide adequate care to a resident with a stage IV pressure ulcer and mental health issues, leading to a deterioration in the resident's condition. Despite being cognitively intact, the resident frequently refused care, including wound treatment and repositioning, which were critical for their health. The facility lacked a specific policy for wound care and failed to implement effective interventions to address the resident's refusal of care, resulting in an Immediate Jeopardy situation.
A resident with a mood disorder and chronic pain exhibited significant behavioral changes, including daily care refusal and wound infestation, which were not properly assessed by the facility. The resident's care plan noted agitation and distress, but interventions were limited to activities and medication without counseling. Despite consistent care refusal and worsening condition, the facility did not identify these behaviors as significant, leading to a failure in addressing the resident's mental instability.
The facility failed to maintain adequate staffing levels, leading to deficiencies in resident care. Staffing shortages resulted in extended work hours for staff and unmet staffing guidelines, affecting the quality of care. Incidents included residents experiencing falls and injuries, with inadequate investigation and reporting. Additionally, medication administration was delayed due to insufficient staff, impacting resident care and safety.
The facility failed to maintain accurate records and timely administration of controlled substances for several residents. A resident with multiple diagnoses did not receive medications on time, and the SSDN confirmed late administration due to staffing issues without documenting provider notification. Two other residents also experienced medication delays, and discrepancies in controlled drug records were noted, indicating a failure in maintaining accurate records.
A facility failed to secure medications properly, as observed when an RN left a medication cart unlocked and unattended with a resident's antifungal medication exposed. The RN admitted the cart should be locked to prevent unauthorized access. The issue was reported to the Administrator for further action.
The facility failed to ensure proper hand hygiene during meal service in one dining room. A NA and a CNA did not sanitize their hands between serving meal trays to residents, and the CNA improperly opened a milk carton with their finger. Interviews confirmed that staff were aware of the importance of hand hygiene to prevent infection spread.
Expired food items were found in the storage and freezer areas of a facility, posing a potential risk of foodborne illness to 92 residents. Observations revealed expired vinegar, cocktail sauce, Italian seasoning, corn chips, fried chicken patties, pork fritters, and uncooked chicken thighs. The Dietary Manager acknowledged the oversight and removed the items.
A resident with severe cognitive impairment was not treated with dignity during meal service, as a CNA/Unit Manager stood over them while assisting with feeding. Facility policy requires staff to sit at eye level with residents to ensure they do not feel inferior, which was not followed in this instance.
A facility failed to maintain resident privacy when a surveyor observed unattended medication carts with open computer screens displaying sensitive information. A nurse admitted to routinely leaving screens open, assuming they would turn off automatically. The DON confirmed this practice violated HIPAA regulations.
The facility failed to maintain a safe environment by leaving hazardous items like ointments, wipes, and razor blades accessible to residents, including those with cognitive impairments. Additionally, a smoking assessment was not conducted for a resident identified as a smoker, contrary to facility policy. Staff interviews confirmed these items should be secured to prevent harm.
The facility failed to properly document the receipt of Ativan oral concentrate, a controlled narcotic, from the pharmacy. This oversight was discovered during a survey, where it was noted that the medication was not recorded in the narcotic book as required. The Director of Nursing confirmed that staff are expected to document such medications immediately upon receipt, but this procedure was not followed, affecting several residents with Ativan prescriptions.
The facility failed to properly store medications, leaving items like collagen wound dressing and iodine swabs unattended in a resident's room. A narcotic box containing Ativan was found unlocked, and medications were left in rooms of residents, increasing the risk of unauthorized access. Staff interviews confirmed these practices were against facility policy.
The facility failed to maintain a safe environment due to missing night light covers and inadequately maintained vinyl flooring, creating potential fall hazards. Staff interviews revealed that the process for reporting maintenance issues was not followed, as neither a CNA nor an LPN reported the flooring problems. The Maintenance Supervisor confirmed the unreported issues and identified them as trip hazards.
A resident with cognitive intactness and physical limitations due to arthritis and pneumonia was left in soiled linens after being incontinent of urine. Despite a care plan requiring staff to clean the perineal area after each episode, the resident reported calling for assistance without timely response. A CNA later confirmed the presence of dried urine on the sheets and acknowledged the need for regular rounding to prevent skin issues. The DON confirmed the expectation for staff to check on residents every two hours, but the policy provided did not apply to the incident.
The facility failed to ensure proper hand hygiene and glove changes during meal service, medication administration, and incontinence care for residents with cognitive impairments. A CNA/Unit Manager did not perform hand hygiene after disposing of an item from the floor before assisting a resident with eating. An RN did not wash hands during medication administration for two residents, and CNAs did not change gloves or wash hands during incontinence care, leading to potential cross-contamination and infection risks.
A facility failed to coordinate with the state office for a PASARR evaluation for a resident with schizophrenia and depressive disorders. The Admission Coordinator did not notify the state office upon the resident's admission, and the LTC MDS Coordinator was unaware of PASARR requirements, relying on personal notes instead of the RAI Manual. This resulted in a deficiency in the admission process and care planning.
A facility failed to include necessary parameters in oxygen orders for a resident with heart failure, chronic kidney disease, and type 2 diabetes mellitus. The resident was observed receiving oxygen at 1.5 liters via nasal cannula without specific parameters in the physician's order, despite the DON acknowledging the importance of such parameters. The facility's oxygen safety policy did not address this requirement.
Failure to Implement Care Interventions Leads to Resident's Decline
Penalty
Summary
The facility failed to implement and modify physical and psychosocial care interventions to meet a resident's activities of daily living needs, resulting in the deterioration of the resident's physical status and eventual death. The resident, who was admitted with a history of morbid obesity, mood disorder, chronic pain, and a stage IV pressure ulcer, consistently refused care, including wound care, repositioning, and personal hygiene. Despite being cognitively intact, the resident's refusal of care was not adequately addressed by the facility, leading to severe neglect. The facility's policies on resident rights and abuse prevention were not effectively implemented, as evidenced by the resident's continued refusal of care and the lack of appropriate interventions to address the resident's needs. The resident was placed on contact isolation due to wound myiasis, yet continued to refuse care, resulting in the presence of maggots in the wound. The facility's failure to exhaust all available remedies and provide necessary care and supervision contributed to the resident's decline. The facility lacked specific policies for wound care and urinary catheters, which further compounded the issue. The resident's care plan included interventions for chronic pain, pressure ulcers, and resistance to care, but these were not effectively executed. The facility's non-compliance with federal regulations on abuse, neglect, and exploitation led to an Immediate Jeopardy situation, highlighting significant deficiencies in the care provided to the resident.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide adequate care and services to prevent the development of new pressure ulcers and promote the healing of existing ones for a resident. The resident, who had a history of chronic pain, anxiety, and depression, was admitted with a stage 4 pressure ulcer and refused wound and incontinence care due to pain. Despite the resident's refusal, the facility did not offer effective interventions such as surgical interventions under anesthesia, intravenous pain medication, or anti-anxiety medication. The Medical Director was not involved in the care, and the Administrator did not participate in resident communications or bedside care plan meetings. The facility's policies and procedures were inadequate, as there was no specific policy for wound care, and the Medical Director's role was not clearly defined. The resident's care plan included interventions for pain management and self-care deficits, but these were not effectively implemented. The resident continued to refuse care, and the facility did not explore alternative interventions or consult with specialists to address the resident's pain and anxiety. The lack of effective communication and coordination among the facility's staff, including the Director of Nursing, Assistant Director of Nursing, and Charge Nurse, contributed to the deficiency. The facility's failure to address the resident's needs and refusal of care resulted in a situation of Immediate Jeopardy, as the non-compliance with care requirements was likely to cause serious harm to the resident. The facility did not adequately assess the resident's mental capacity or provide counseling or therapy sessions to address the resident's behavioral health needs. The lack of involvement from the Medical Director and Administrator, along with the absence of a comprehensive care plan, further exacerbated the situation, leading to the deficiency.
Failure to Provide Adequate Care for Resident with Pressure Ulcer and Mental Health Issues
Penalty
Summary
The facility failed to provide appropriate treatment and services to a newly admitted resident who refused activities of daily living (ADL) care, assistance, and wound care. The resident, who had a history of mental disorder and psychosocial adjustment difficulties, was not adequately assessed or treated for pressure wounds, leading to a deterioration in their mental and psychosocial health. The facility's non-compliance with participation requirements was determined to have caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The resident was admitted with multiple diagnoses, including a stage IV pressure ulcer, morbid obesity, mood affective disorder, and chronic pain. Despite being cognitively intact, the resident frequently refused care, including wound treatment, turning, and repositioning, which were critical for their health. The facility lacked a specific policy for wound care and failed to implement effective interventions to address the resident's refusal of care and the associated risks. The facility's staff, including the Administrator, Director of Nursing, and other nursing staff, did not adequately address the resident's needs or provide necessary interventions to prevent further decline. The resident's care plan included various interventions, but these were not effectively implemented or adjusted in response to the resident's refusal of care. The facility's failure to provide adequate care and services resulted in an Immediate Jeopardy situation, highlighting significant deficiencies in the facility's management and oversight of resident care.
Failure to Identify and Assess Resident's Behavioral Symptoms
Penalty
Summary
The facility failed to accurately identify and assess a resident's verbal, physical, or other self-directed behavior symptoms as potential indicators of mental instability. The resident, admitted with diagnoses including unspecified mood disorder, chronic pain, and treatment refusal, exhibited a significant change in behavior that was not properly assessed. The Minimum Data Set (MDS) assessment did not identify any potential indicators for psychosis or behavioral symptoms, despite the resident's daily rejection of care behaviors and worsening behavior status. The resident's care plan, last modified in October 2024, noted agitation and distress due to pain, with interventions aimed at boosting self-esteem through activities. However, the resident refused various care interventions, including wound care, skin assessments, and personal hygiene, leading to a wound infestation issue. The Social Services Director (SSD) conducted interviews and reviewed notes but did not identify verbal behavior or other self-directed behaviors as significant, considering them the resident's baseline rather than new behaviors. Progress notes revealed a pattern of care refusal, with the resident consistently rejecting personal care, meals, and medical interventions. The resident's refusal led to a decline in their condition, including a stage IV open wound with maggot infestation. Despite being informed of the risks, the resident continued to refuse care, and the facility's attempts to involve Adult Protective Services and the ombudsman did not result in a resolution. The SSD acknowledged in hindsight that the behaviors should have been assessed as significant, but at the time, they did not trigger further assessment questions.
Staffing Shortages Lead to Deficiencies in Resident Care
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the needs of its residents, as evidenced by not adhering to its own staffing guidelines for 74 of 87 shifts reviewed. The facility's assessment indicated specific staffing needs per shift, which were not met, leading to numerous instances of staff working extended hours and shifts being understaffed. This lack of adequate staffing was observed across various shifts, with significant shortages in RNs, LPNs, CNAs, and other support staff, impacting the quality of care provided to residents. The report highlights several incidents involving residents that underscore the consequences of insufficient staffing. For instance, one resident with severe cognitive impairment and a history of falls experienced multiple unwitnessed falls, resulting in injuries such as a head bruise and a cervical fracture. Another resident, also with cognitive impairments, suffered a fall from a wheelchair, leading to a cervical spine fracture and a forehead laceration. These incidents were not properly investigated or reported to the state agency, as they were not considered injuries of unknown origin by the facility. Additionally, the report details medication administration issues due to staffing shortages. Residents reported delays in receiving their medications, with some medications being administered hours after the scheduled time. This delay in medication administration was attributed to the lack of available staff, as nurses were required to cover multiple halls and manage a high number of residents. The Director of Nursing acknowledged the challenges in managing staff and the potential consequences of delayed medication administration, such as inadequate pain management and risks associated with blood pressure medications being given too close together.
Medication Administration and Record-Keeping Deficiencies
Penalty
Summary
The facility failed to maintain accurate records and administration of controlled substances for several residents. Specifically, the facility did not maintain an account of all controlled substances on one of the medication carts and failed to keep accurate records for four residents across two medication carts. Additionally, the facility did not ensure that medications were administered within the specified time to maintain therapeutic status for three residents who reported not receiving their medications on time. Resident #26, who was admitted with multiple diagnoses including polyneuropathy, depression, and hypertension, did not receive their medications on time. The medication administration audit revealed that the resident's medications, including antihypertensive and opioid pain medications, were administered late. The resident was observed requesting pain medication and reported not receiving their morning medications. The Social Services Discharge Nurse (SSDN) confirmed the late administration due to staffing issues and did not document provider notification for the late administration. Similarly, Resident #27 and Resident #28 also experienced delays in receiving their medications. Resident #27, with diagnoses of hypothyroidism, major depressive disorder, and anxiety, received their medications several hours late, and the second doses were not adjusted accordingly. Resident #28, who had moderate cognitive impairment and was receiving opioid pain medication, also received their medications late. The Director of Nursing acknowledged the delays and the lack of provider notification, which was not documented in the progress notes. Additionally, discrepancies in the controlled drug sign-out book were noted, with missing pills and incorrect counts on medication cards, indicating a failure in maintaining accurate controlled substance records.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that medications were stored securely, as observed during a survey. A Registered Nurse (RN) was seen administering medication at the end of a hallway, leaving the medication cart unlocked and unattended. Additionally, a medication card for a resident was left on top of the cart, and the computer screen was left open. The RN acknowledged the oversight, stating that the cart should be locked to prevent unauthorized access. The specific incident involved a resident's antifungal medication, which was left in an un-popped bubble on the medication cart. This situation was brought to the attention of the facility's Administrator, who was informed of the potential danger by the surveyor. The Nurse Consultant indicated that they would address the issue with the RN involved.
Failure in Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to ensure proper hand hygiene was performed during meal service in one of the four dining rooms observed. Specifically, Nursing Assistant (NA) #9 and Certified Nursing Assistant (CNA) #10 did not perform hand hygiene before or between serving meal trays to residents in the 100-hall dining room. NA #9 served meals to seven residents without sanitizing hands between trays, while CNA #10 served meals to two male residents without performing hand hygiene and opened a milk carton with their finger, which was not sanitized. Interviews with the staff involved, including NA #9 and CNA #10, revealed an acknowledgment of the importance of hand hygiene to prevent the spread of infections. Both staff members admitted that hands should have been sanitized between serving meal trays and that inserting a finger into the milk carton opening was inappropriate. The facility's Administrator also confirmed that hand hygiene should be performed between serving trays to prevent infection spread.
Expired Food Items Found in Storage and Freezer
Penalty
Summary
The facility failed to ensure that expired food items were promptly removed from stock, which could potentially lead to foodborne illness for the 92 residents receiving meals from the kitchen. During an observation of the dry goods storage area, several expired items were found, including three plastic gallon jugs of red vinegar, ten individual serving containers of cocktail sauce, an open package of Italian seasoning, and fourteen bags of corn chips. These items were all past their use-by dates and were still present in the storage area, indicating a lapse in the facility's food safety practices. The Dietary Manager acknowledged that expired items should not be in the storage room and proceeded to remove them. Further observations in the walk-in refrigerator and freezer revealed additional expired food items, including six fried chicken patties with visible frost, ten pork fritters in a torn bag, seven more fried chicken patties, and a solid mass of uncooked boneless chicken thighs, all labeled with past use-by dates. The Dietary Manager confirmed that these outdated items should not be in the freezer and should not be served to residents. This oversight in monitoring and removing expired food items from storage areas highlights a significant deficiency in the facility's food safety management.
Failure to Maintain Resident Dignity During Meal Service
Penalty
Summary
The facility failed to maintain and promote the dignity of a resident during meal service. The deficiency was identified through record review, observations, and interviews. A resident with severe cognitive impairment, as indicated by a BIMS score of 2, required limited assistance for eating due to a self-care performance deficit related to dementia. During meal service, a CNA/Unit Manager was observed standing over the resident while assisting with feeding, which is contrary to the facility's policy of sitting at eye level with residents to ensure they do not feel inferior. Interviews with the CNA/Unit Manager, the Assistant Director of Nursing/Infection Control Preventionist, and the Director of Nursing confirmed that staff are expected to sit at eye level with residents during meal service to maintain their dignity. The facility's policy emphasizes the importance of treating residents with respect and dignity, which includes sitting down next to them during meals. The failure to adhere to this policy resulted in a deficiency related to the resident's right to a dignified existence.
Privacy Breach of Resident Information
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' personal and medical records, as required by their documented Resident Rights. On two separate occasions, a surveyor observed unattended medication carts in a public hallway with computer screens displaying sensitive resident information. Resident #46's Medication Administration Record (MAR) was visible, showing medications and personal health information, while Resident #392's screen displayed their picture and medication details, including Hydrocodone. These incidents occurred on the 600 Hall, where passersby could easily view the information. Registered Nurse (RN) #6, responsible for the medication carts, admitted to routinely leaving the screens open, believing they would automatically turn off. The Director of Nursing (DON) later confirmed that leaving computer screens open with resident information in public areas constitutes a Health Insurance Portability and Accountability Act (HIPAA) violation. The residents involved had varying cognitive abilities, with Resident #46 having severe cognitive impairment and Resident #392 being cognitively intact, as indicated by their Brief Interview for Mental Status (BIMS) scores.
Failure to Maintain a Safe Environment
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for its residents, as evidenced by several observations and interviews. Resident #49, who was severely cognitively impaired, had a full tube of moisture barrier ointment left unattended in their room on multiple occasions. Staff interviews revealed that such ointments should be stored in a locked treatment or wound care cart to prevent resident access. Similarly, Resident #56, also severely cognitively impaired, had germicidal disposable wipes left out in their bathroom, which staff confirmed should be stored securely to prevent potential harm. Additionally, the facility did not conduct a smoking assessment for Resident #295, who was identified as a smoker with intact cognition. Despite being observed smoking with supervision and wearing protective gear, there was no documented smoking assessment in the resident's electronic health record. This oversight contradicts the facility's smoking policy, which mandates assessments upon admission and at regular intervals to ensure safe smoking practices. The facility also failed to secure hazardous items such as handheld razor blades, spray oil-based lubricant, and disinfectant wipes, which were left unattended on a maintenance cart in a resident hallway. Interviews with staff, including the DON, confirmed that such items should not be left unattended due to the risk they pose to residents. Furthermore, aerosol anti-perspirant was observed left out in the rooms of residents with cognitive impairments, contrary to safety protocols that require such items to be locked away. The facility lacked hazard policies to guide staff in preventing these safety lapses.
Failure to Document Controlled Narcotics
Penalty
Summary
The facility failed to ensure proper documentation of controlled narcotics, specifically Ativan oral concentrate, when acquired from the pharmacy. This deficiency was identified during an observation and record review by a surveyor. The surveyor found that there was no documentation for Ativan oral concentrate in the narcotic book, which is required to prevent misappropriation and ensure a record of receipt and disposition. Registered Nurse (RN) #1 acknowledged that the nurse who accepted and signed for the delivery should have documented the medication in the controlled narcotic book. The Director of Nursing (DON) later provided documentation showing that Ativan was received on a specific date, but the initial lack of documentation posed a risk of medication misappropriation. The deficiency had the potential to affect five residents who had a physician's order for Ativan. The facility's policy titled 'Medication Storage in the Facility' did not address the documentation of the receipt, documentation, and disposition of medications from the pharmacy. The DON stated that nursing staff are expected to count the medication with the delivery driver, sign the manifest, and immediately document the medication in the logbook to prevent any discrepancies. However, this procedure was not followed, leading to the deficiency noted by the surveyor.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure proper storage of medications and biologicals, leading to potential safety risks for residents. In the case of Resident #49, who was admitted with muscle wasting and dementia, surveyors observed unattended packages of ultra powder collagen wound dressing and iodine swabs in the resident's room over several days. Interviews with staff, including a CNA, LPN, and the Director of Nursing (DON), confirmed that these items should have been stored in a locked wound care cart to prevent resident access. Additionally, the facility did not secure a narcotic box in the medication room, which contained controlled substances such as Ativan. The box was found unlocked, and RN #1 acknowledged that it should have been secured behind at least two locks. The Maintenance Supervisor and Administrator were aware of the issue, and a letter dated prior to the survey indicated the lock was not functioning. The DON confirmed that no residents were approved for self-administration of medications, emphasizing the importance of securing controlled substances. Further deficiencies were noted with Residents #72 and #342. For Resident #72, medications including nasal spray and a corticosteroid inhaler were left unattended in the room, despite the resident being cognitively intact. LPN #2 admitted to leaving these items and acknowledged the risk of other residents accessing them. Similarly, an open, undated bottle of sodium chloride was found in Resident #342's room, which LPN #2 confirmed was against standard practice. The presence of wandering residents increased the risk of unauthorized access to these medications.
Deficiency in Maintaining Safe Environment Due to Unreported Flooring Issues
Penalty
Summary
The facility failed to maintain a safe and functional environment, as evidenced by missing night light covers for two residents and inadequately maintained vinyl flooring in the 300 hall secure unit. Observations revealed multiple instances of missing vinyl tiles at doorway thresholds, creating gaps in the floor. These gaps were found in several rooms, with measurements indicating significant areas of missing flooring, which could potentially cause falls. Interviews with staff, including a CNA and an LPN, indicated that the process for reporting maintenance issues involved placing a work order in a designated drop box. However, neither staff member had reported the flooring issues, despite acknowledging the potential hazard. The Maintenance Supervisor confirmed that the areas had not been reported and identified the missing flooring as a trip hazard. The lack of reporting and subsequent inaction contributed to the deficiency in maintaining a safe environment.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely and necessary services to maintain good hygiene for a resident who was unable to perform personal care independently. The resident, diagnosed with depressive disorders, bipolar disorder, and rheumatoid arthritis, was occasionally incontinent of urine and required assistance for toilet use. Despite having a care plan that instructed staff to clean the perineal area with each incontinence episode, the resident reported being left in soiled linens after calling for assistance earlier in the morning. The resident expressed an inability to change the linens due to physical limitations and a recent bout of pneumonia. During the survey, a CNA confirmed the presence of a brown spot on the resident's sheets, indicating dried urine, and acknowledged that staff should round every two hours to prevent skin breakdown and infection. The resident also reported having a rash in the perineal area. The Director of Nursing confirmed that staff are expected to check on residents every two hours and provide necessary personal care. However, the policy provided by the Administrator did not apply to the situation, and the CNA involved had been trained in incontinent care prior to the incident.
Inadequate Hand Hygiene and Glove Use in Care Activities
Penalty
Summary
The facility failed to ensure proper hand hygiene and glove changes during various care activities, leading to potential cross-contamination and infection risks. During meal service, a CNA/Unit Manager assisted a resident with severe cognitive impairment without performing hand hygiene after disposing of a container of ice cream from the floor. This oversight occurred despite the facility's policy emphasizing hand hygiene as a primary means to prevent infection spread. In another instance, an RN did not perform hand hygiene during medication administration for two residents, one with severe cognitive impairment and another who was cognitively intact. The RN handled medications and entered and exited residents' rooms without washing hands, contrary to the facility's standard precautions policy, which requires handwashing between resident contacts to prevent microorganism transfer. Additionally, during incontinence care for two residents with severe cognitive impairment, CNAs failed to perform hand hygiene or change gloves between dirty and clean tasks. This included handling soiled briefs and clean items without proper glove changes, increasing the risk of cross-contamination. The facility's policies and training programs emphasize the importance of hand hygiene and glove changes to prevent healthcare-associated infections, yet these practices were not followed during the observed care activities.
Failure to Complete PASARR Evaluation for Resident
Penalty
Summary
The facility failed to coordinate with the state-designated office to ensure a proper evaluation for a resident under the Preadmission Screening and Resident Review (PASARR) process. Resident #44, who was admitted with diagnoses including schizophrenia and recurrent depressive disorders, did not have the necessary PASARR evaluation completed. The facility received a letter from the State Designated Professional Associates indicating the need to contact them upon the resident's admission to receive the completed PASARR evaluation, but this step was not taken. The Admission Coordinator, responsible for ensuring PASARRs are completed, was unable to confirm whether the State Designated Professional Associate was notified of the resident's admission or if the PASARR evaluation was received. This lack of communication and follow-up was evident during interviews with the Admission Coordinator, who stated they would need to check with the Administrator for guidance. The failure to notify the state office and obtain the PASARR evaluation resulted in a deficiency in the facility's admission process. Additionally, the LTC MDS Coordinator was unaware of the PASARR requirements and did not utilize the RAI Manual for guidance on completing the necessary sections of the MDS. The LTC MDS Coordinator admitted to relying on personal notes rather than the RAI Manual, which led to a lack of awareness regarding the PASARR process. This oversight contributed to the deficiency, as the facility did not ensure that the resident's care plan addressed the services specified in the Level II PASARR determination and evaluation report.
Failure to Include Oxygen Parameters in Resident Care
Penalty
Summary
The facility failed to ensure that oxygen orders for a resident included necessary parameters to prevent respiratory complications. Resident #12, who has diagnoses of heart failure, chronic kidney disease, and type 2 diabetes mellitus, was observed receiving oxygen at 1.5 liters via nasal cannula on multiple occasions. The resident's electronic health record included a physician's order for oxygen to be administered as needed for oxygen saturation levels below 90. However, the order lacked specific parameters for oxygen administration. The Director of Nursing acknowledged that oxygen orders should include parameters to prevent excessive oxygen administration, which can be harmful. Despite this, the facility's policy on oxygen safety did not address the need for such parameters.
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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