Ouachita Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Camden, Arkansas.
- Location
- 1411 Country Club Road, Camden, Arkansas 71701
- CMS Provider Number
- 045207
- Inspections on file
- 27
- Latest survey
- August 21, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Ouachita Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that expired food items, such as buttermilk and bread, were not promptly removed from storage, and opened bags of hamburger buns were left unsealed, exposing them to contamination. Ice scoop holders were dirty, and dietary staff failed to follow hand hygiene protocols, handling clean equipment and food items after touching dirty surfaces without washing their hands. These deficiencies were confirmed through staff interviews and direct observation.
A cognitively impaired resident with a history of sexual behaviors engaged in a sexual act with a staff member, which was witnessed by another staff and reported to administration and law enforcement. Despite ongoing reports of the resident's inappropriate sexual behaviors, the facility did not implement adequate supervision or interventions, and the abuse policy lacked specific guidance on sexual abuse prevention. The resident's care plan and assessments failed to accurately document these behaviors or address the risk, contributing to the incident.
A resident with moderate to severe cognitive impairment and a history of inappropriate sexual behaviors did not have these behaviors identified or addressed in their care plan. Despite multiple incidents involving public sexual acts and sexual contact with staff and other residents, the care plan lacked goals, interventions, or assessments for consent, and there were no physician orders for safe sex education or competency evaluation. Staff were aware of the behaviors but did not implement formal interventions or update the care plan until after a significant incident occurred.
A resident with Alzheimer's and moderate dementia did not consistently receive care plan interventions, including the use of AFO braces and protective sleeves, leading to skin integrity issues. CNAs were unaware of some care requirements, and the facility lacked a policy on care plans.
The facility failed to ensure proper hand hygiene and glove usage among dietary staff, leading to potential cross-contamination. Additionally, the facility did not maintain proper food storage and quality standards, with dented cans, discolored lettuce, and improperly stored leftovers observed. The physical environment of the kitchen and dishwashing areas was also not maintained in a clean and sanitary condition, with residue, stains, and chipped surfaces noted.
The facility failed to prevent the misappropriation of narcotics for two residents, leading to discrepancies in medication counts and inadequate pain management. An LPN admitted to not signing out medications immediately and incorrectly documenting administration times. The DON was notified but did not know how to handle the situation. One resident reported significant pain but did not receive medication.
The facility failed to follow the planned menu for resident meals, resulting in residents on pureed diets not receiving pureed Spanish rice and residents on mechanical soft diets not receiving tortilla bread. The dietary employee admitted to overlooking these items.
The facility failed to ensure that pureed food items were blended to a smooth, lump-free consistency, affecting five residents on pureed diets. Observations revealed that pureed beef enchilada, vegetable blends, flour tortillas, and sausage were not prepared correctly, posing a risk of choking or other complications.
The facility failed to ensure proper hand hygiene and glove changes during perineal care for two residents, potentially affecting seven residents. Additionally, housekeeping staff did not perform hand hygiene during clean laundry delivery. The facility also failed to adhere to droplet precautions for residents with COVID-19, affecting all 78 residents.
The facility failed to ensure privacy and dignity for a resident during daily care activities. CNAs did not close the window shade or the room door, exposing the resident. Staff interviews confirmed that privacy protocols were not followed.
A resident's personal and medical information was left exposed on an unlocked medication cart and computer, compromising their privacy. The incident was confirmed by both the LPN and the nursing administration, highlighting a failure to adhere to the facility's confidentiality policies.
A facility failed to ensure a bathroom sink in a resident's room was properly attached to the wall, leading to a potential hazard. The Maintenance Director confirmed the sink was loose due to residents using it to push themselves up, and acknowledged that the screws were coming loose. The issue was later addressed and fixed.
The facility failed to complete the PASRR Level 1 pre-screening for a resident with bipolar II disorder before admission. The screening was delayed until well after the resident's admission date. The ADON confirmed the delay and noted the absence of a policy for MDS or PASRR.
The facility failed to provide perineal care in accordance with professional standards for two residents with severe cognitive impairment. CNAs did not follow proper hygiene practices, including changing gloves and sanitizing hands, and used inadequate wiping techniques. This non-compliance with established protocols highlights significant lapses in the quality of care.
The facility failed to follow manufacturer guidance during the transfer of a resident using a sit-to-stand lift, resulting in unsafe practices. The resident, who has severe cognitive impairment, was transferred without the required buttock strap, and their left hand was forcibly placed on the handle. This deficiency has the potential to affect other residents requiring similar transfers.
The facility failed to ensure a resident's peg tube was flushed with the prescribed 60 cc of water before and after medication administration, instead using only 30 cc. This discrepancy was confirmed by an LPN and the ADON, who acknowledged the potential complications of not following the physician's orders.
The facility failed to ensure medications were stored and labeled correctly, with instances of medications left in residents' rooms, incorrect self-administration of nasal spray by a resident, and medication carts left unlocked and unattended by LPNs.
Deficient Food Storage, Expired Items, and Hand Hygiene in Dietary Services
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food storage, preparation, and handling practices. Expired food items, including a half-gallon of buttermilk and three bags of bread, were found in storage past their expiration dates, despite the Dietary Manager's routine checks. Additionally, several opened bags of hamburger buns were left unsealed, exposing them to environmental contaminants and potential pests. Ice scoop holders attached to ice chests were found to be dirty, with residue at the bottom, and the scoops were resting directly on the unclean surfaces. Staff interviews confirmed that cleaning responsibilities for these items were not consistently followed. Dietary staff were also observed failing to adhere to proper hand hygiene protocols. One dietary aide turned off a faucet with bare hands and then handled clean glasses without washing hands. Another aide handled milk cartons, shakes, and condiments, then picked up cups and glasses by the rims without washing hands after touching potentially dirty objects. A third staff member touched a blender motor and then handled clean equipment without washing hands. These actions were in direct violation of the facility's hand washing policy, which requires hand hygiene after contact with dirty equipment or surfaces and before handling clean items.
Failure to Protect Cognitively Impaired Resident from Sexual Abuse by Staff
Penalty
Summary
A cognitively impaired resident with a history of stroke, moderate dementia, and mood disorders was involved in a sexual act with a staff member, specifically a housekeeper, within the facility. The incident was witnessed by a CNA, who observed the resident performing oral sex on the housekeeper in the resident's bathroom. The event was reported to the facility administrator and local law enforcement, and the housekeeper was immediately terminated. The resident had a documented history of sexual behaviors with other residents and staff, as reported by multiple employees, but these behaviors were not consistently identified or addressed in the resident's Minimum Data Set (MDS) assessments or care plan documentation. Despite the resident's ongoing sexually inappropriate behaviors, the facility failed to implement adequate interventions or supervision to prevent such incidents. Staff interviews revealed that the resident was known for groping and attempting sexual contact with both staff and other residents, yet there were no specific measures in place to restrict unsupervised access to the resident by male staff or to ensure staff were not alone with the resident. The facility's abuse and neglect policy did not specifically address sexual abuse, nor did it provide clear guidance or training for staff on recognizing, preventing, or intervening in cases of sexual abuse involving residents. The facility's documentation and care planning did not accurately reflect the resident's sexual behaviors or risk for abuse, and there was a lack of physician orders or assessments regarding the resident's capacity to consent to sexual activity. Interviews with facility leadership and clinical staff indicated uncertainty about how to assess sexual consent capacity and how to manage residents with hypersexual behaviors. The failure to identify, document, and address the resident's risk for sexual abuse, combined with insufficient staff training and supervision, directly contributed to the occurrence of sexual activity between the resident and a staff member.
Failure to Address and Care Plan Resident Sexual Behaviors
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan that addressed a resident's sexual behaviors, resulting in the absence of goals, interventions, or plans for safe sexual activity, assessment of competency for consent, redirection from other residents, and protection from unethical staff. Despite multiple documented incidents of inappropriate sexual behaviors, including public sexual acts and sexual contact with both staff and other residents, the care plan did not reflect these behaviors or provide specific interventions to address them. The care plan only noted the resident as sexually active and included general statements about respecting privacy during sexual activity with consenting partners, without addressing the resident's cognitive impairment or the need for consent assessment. The resident in question had a history of stroke, hemiplegia, moderate dementia, major depressive disorder, mood disorder, and anxiety disorder, with consistently low BIMS scores indicating severe to moderate cognitive impairment. Multiple MDS assessments failed to identify any sexual behaviors, despite staff and witness reports of ongoing inappropriate sexual conduct. Staff interviews and documentation revealed that the resident engaged in repeated sexual behaviors, including grabbing and touching staff and other residents, and was involved in an incident of oral sex with an employee. However, there were no physician orders for safe sex education, STD screening, or competency evaluation for sexual consent. Interviews with staff, including the DON, Administrator, and APRNs, confirmed that the resident's sexual behaviors were known and discussed, but no formal interventions or care plan updates were made to address these behaviors until after a significant incident occurred. Staff relied on informal redirection and discussions with the resident's representative, but there was no policy or procedure in place to manage such behaviors, nor were there documented interventions to prevent further incidents or protect the resident and others from harm.
Failure to Implement Care Plan Interventions
Penalty
Summary
The facility failed to consistently implement care plan interventions for a resident diagnosed with Alzheimer's disease and moderate dementia with agitation. The resident was severely cognitively impaired and required assistance with personal hygiene. The care plan indicated the resident was non-weight bearing due to dementia and required bilateral AFOs for foot drop when out of bed, as well as protective sleeves to prevent impaired skin integrity. However, observations revealed that the resident was not wearing the protective sleeves or AFO braces on multiple occasions, leading to broken skin areas with dried blood on the resident's arm. Interviews with CNAs confirmed that the care plan was the primary source of information for resident care, yet there was a lack of awareness regarding the requirement for AFO braces. The facility did not have a policy or procedure on care plans, as confirmed by the Administrator. The Assistant Director of Nursing acknowledged the presence of AFO braces in the resident's room and confirmed their necessity as per the care plan. This lack of consistent implementation of the care plan interventions contributed to the deficiency identified by the surveyors.
Improper Hand Hygiene and Food Storage Practices
Penalty
Summary
The facility failed to ensure proper hand hygiene and glove usage among dietary staff, leading to potential cross-contamination. Observations revealed that dietary employees handled clean dishes and food items without washing their hands after touching dirty objects. For instance, one dietary employee touched a dirty coffee cup and a clipboard, then handled clean glasses and plates without washing her hands. Another dietary employee used a water hose to clean plates and then handled clean plates without washing his hands. Additionally, a dietary employee contaminated her gloves by touching a spray bottle and then handled tortillas without changing gloves or washing her hands. A CNA also failed to sanitize her hands before handling food tray covers, touching the inside of the covers with her fingers and thumbs, which was confirmed by an RN as improper practice. The facility also failed to maintain proper food storage and quality standards. Dented cans of pumpkin and peach pie filling were found on a rack with non-dented cans. In the walk-in refrigerator, leftover sausage, scrambled eggs, and bacon were stored in plastic bags for use the next day, and discolored shredded lettuce was observed. In the walk-in freezer, an opened box of beef patties was not covered or sealed. An opened bottle of lemon juice was stored in the storage room instead of being refrigerated as per the manufacturer's specifications. The physical environment of the kitchen and dishwashing areas was not maintained in a clean and sanitary condition. Observations included gray/black residue on the ceiling/wall above a metal rack, rotted and chipped door frames, missing baseboards with accumulated residue, brown stains on the ceiling air conditioning cover, peeling paint exposing cement, rust and black stains around the 3-compartment sink, oven, and fluorescent lights, and chipped floors with black stains. The storage room had black residue in the corners where the wall and ceiling meet, which was described by the Dietary Supervisor as looking like mildew.
Misappropriation of Narcotics and Inadequate Pain Management
Penalty
Summary
The facility failed to prevent the misappropriation of narcotics for two residents, leading to discrepancies in the controlled medication count and potential complications in pain management. On 05/14/2024, the surveyor observed that the controlled medication on hand did not match what was documented in the narcotic book for two residents. Specifically, there were discrepancies in the counts of Pregabalin, Oxycodone, and Hydromorphone. An LPN admitted to not signing out the medications immediately after administration and incorrectly documenting the administration times. The LPN also altered the administration time after being informed of the discrepancies by the surveyor. The Director of Nursing (DON) was notified of the discrepancies but admitted to not knowing how to handle the situation. Additionally, one of the residents reported not receiving any pain medication despite experiencing significant pain during therapy. The therapist confirmed that the resident had reported pain but did not inform the nurse, as she did not believe the pain was severe. This series of actions and inactions led to the misappropriation of narcotics and inadequate pain management for the residents involved.
Failure to Follow Planned Menu for Resident Meals
Penalty
Summary
The facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents. During the noon meal service, residents who required pureed diets were not served pureed Spanish rice as specified on the menu, and no substitutes were provided. Additionally, residents on mechanical soft diets did not receive the tortilla bread that was listed on the menu. The dietary employee admitted to overlooking these items, resulting in the deficiency observed by the surveyor.
Failure to Ensure Proper Consistency of Pureed Food
Penalty
Summary
The facility failed to ensure that pureed food items were blended to a smooth, lump-free consistency, which is necessary to minimize the risk of choking or other complications for residents requiring pureed diets. During observations on 05/13/2024, Dietary Employee (DE) #3 prepared pureed beef enchilada, vegetable blends, and flour tortillas, all of which were found to have inappropriate consistencies. The pureed beef enchilada was gritty, the vegetable blend did not form properly, and the flour tortilla was thick, sticky, and lumpy. Both DE #3 and a certified nursing assistant confirmed these observations when questioned by the surveyor. On 05/14/2024, the pureed sausage served for breakfast was also found to be lumpy and not smooth. This was confirmed by a certified nursing assistant and the Director of Nursing, who noted that the consistency was more like mechanical rather than pureed. The kitchen was asked to prepare another batch of pureed sausage, which was then compared to the initial serving. DE #3 acknowledged that the initial pureed sausage was not smooth. These deficiencies had the potential to affect five residents who were on pureed diets.
Failure to Ensure Proper Hand Hygiene and Droplet Precautions
Penalty
Summary
The facility failed to ensure proper hand hygiene and glove changes during perineal care for two residents. Observations revealed that CNAs did not perform hand hygiene upon entering the residents' rooms or before starting care. Additionally, gloves were not changed during the perineal care process, and hand hygiene was not performed between glove changes. This failure was observed during the care of two residents who required assistance with perineal care, potentially affecting seven residents in total. The CNAs also failed to provide adequate privacy by not closing window shades before exposing the residents during care. The facility's policy on hand hygiene and perineal care was not followed, as confirmed by interviews with the CNAs and the Director of Nursing (DON). The facility also failed to ensure proper hand hygiene during clean laundry delivery. Housekeeping staff did not perform hand hygiene before entering or after exiting residents' rooms while delivering clean laundry. The housekeeping staff was not adequately trained on the importance of hand hygiene, as evidenced by the absence of their signatures on the inservice education reports. The DON confirmed that there was no specific hand hygiene policy for laundry handling, and the housekeeping staff was not instructed to sanitize their hands before entering rooms. Additionally, the facility failed to adhere to droplet precautions for residents with COVID-19. Residents on droplet precautions were observed with their doors open, and some residents were seen without masks while outside their rooms. Staff, including the maintenance man, did not consistently wear personal protective equipment (PPE) when entering rooms with droplet precaution signs. The Infection Preventionist and RN confirmed that residents with COVID-19 should remain in their rooms with the doors closed to prevent the spread of the virus. The facility's failure to follow droplet precautions affected all 78 residents in the building.
Failure to Ensure Resident Privacy and Dignity
Penalty
Summary
The facility failed to ensure privacy and dignity for Resident #14 during activities of daily living care. On 05/13/2024, CNAs #3 and #4 entered Resident #14's room to perform a brief change and peri-care. During the procedure, CNA #3 removed the resident's brief while the window shade was open, exposing the resident's abdomen, private area, and legs. CNA #4, who was standing in front of the window, looked out twice before closing the shade. Additionally, the room door was left open during the resident's transfer from the bed to a wheelchair, and CNA #8 entered without knocking, further compromising the resident's privacy. Interviews with the staff, including CNAs #3, #4, and #8, as well as the Director of Nursing (DON) and the Administrator, confirmed that privacy protocols were not followed. CNA #4 acknowledged that the window shade should have been closed before removing the brief, and CNA #3 admitted that privacy should have been provided prior to care. The DON and the Administrator both emphasized the importance of maintaining privacy and dignity during resident care, including knocking and announcing before entering a resident's room.
Failure to Protect Resident's Confidential Information
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of Resident #178's personal and medical information. Resident #178, who had a diagnosis of Depression and Cerebral Infarction, was cognitively intact as per the Quarterly Minimum Data Set (MDS) assessment. On 05/15/24, a surveyor observed that the medication cart in the hallway outside Resident #178's room was left unlocked with the keys in the lock. Additionally, the laptop on the cart was open and displayed the resident's Electronic Medication Administration Record (E-MAR) profile, which included personal and medical information. This information was left unattended and accessible to unauthorized individuals. LPN #3 confirmed the medication and computer were left unattended and unlocked, exposing the resident's confidential information. On 05/16/24, both the Director of Nursing and the Assistant Director of Nursing confirmed that unauthorized individuals could view sensitive resident information if the computer screen was left unlocked. The facility's policy on confidentiality, which was presented to the surveyor, emphasized the importance of protecting residents' personal and medical records. An in-service training on HIPAA compliance highlighted that leaving resident information visible and unattended was a violation. Despite these policies, the incident demonstrated a failure to comply with the facility's confidentiality standards, thereby compromising Resident #178's privacy.
Improperly Attached Sink in Resident's Bathroom
Penalty
Summary
The facility failed to ensure a bathroom sink in room [ROOM NUMBER] was properly attached to the wall, which had the potential to affect one resident who had access to the room. During an observation, the sink was found not flush with the wall, with caulking material spread in globs and an open gap behind the cold-water knob. The Maintenance Director confirmed that the sink was loose due to residents using it to push themselves up, and acknowledged that the screws holding the sink were coming loose, which could potentially cause the sink to fall. Subsequent observations showed that the sink was later fixed, with no movement or gaps present. The Administrator stated that there is a preventative maintenance program in place, and the Maintenance Director rounds the facility daily to address maintenance issues. The Maintenance Director confirmed that urgent needs are addressed immediately, while basic needs are handled as time allows. The Maintenance Director also acknowledged that the issue with the sink in room [ROOM NUMBER] was addressed right away after being identified.
Failure to Complete PASRR Level 1 Pre-Screening Prior to Admission
Penalty
Summary
The facility failed to ensure a referral for Pre-Admission Screening and Resident Review (PASRR) was made for a resident reviewed for PASARR. Specifically, the facility did not complete the PASRR Level 1 pre-screening for a resident with bipolar II disorder prior to admission. The resident was admitted on 03/30/2024, and the PASRR Level 1 screening was only completed on 05/14/2024, well after the admission date. The resident's Care Plan, revised on 04/10/2024, indicated the presence of bipolar disorder and depression, with interventions in place for managing these conditions. During interviews, the Assistant Director of Nursing (ADON) confirmed that she was responsible for PASRR screenings since starting at the facility on April 12, 2024. The ADON acknowledged that PASRR Level 1 screenings should be completed before admission and confirmed that the screening for the resident in question was delayed until 05/14/2024. Additionally, the ADON stated that the facility did not have a policy for Minimum Data Set (MDS) or PASRR, indicating a lack of procedural guidelines for these critical assessments.
Deficient Perineal Care and Hygiene Practices
Penalty
Summary
The facility failed to provide perineal care in accordance with professional standards of care for two residents, leading to deficiencies in hygiene and infection control. Resident #14, who had severe cognitive impairment and was dependent on staff for toileting hygiene, was observed receiving inadequate perineal care. Certified Nursing Assistants (CNAs) #3 and #4 used only one wipe to clean the resident's private area and buttocks, did not change gloves or sanitize hands during the process, and were unsure if the resident was circumcised. This improper technique and lack of hygiene could potentially affect other residents requiring similar care in the same hall. Resident #52, also with severe cognitive impairment and dependent on staff for toileting hygiene, experienced similar deficiencies. During the perineal care process, CNA #3 did not perform hand hygiene, used inadequate wiping techniques, and failed to change gloves. Additionally, the resident was transferred using a lift with improper technique, causing discomfort and potential risk of injury. The CNAs did not follow the facility's peri-care procedure, which includes specific steps for cleaning, glove changes, and hand hygiene. The facility's policies and procedures for perineal care and hand hygiene were not adhered to by the CNAs, despite having been trained and evaluated on these procedures. The facility's in-service education reports indicated that the CNAs had received training on the importance of good hand hygiene and the proper use of hand sanitizers, yet these practices were not followed during the observed care. This failure to comply with established protocols highlights significant lapses in the quality of care provided to the residents.
Improper Use of Sit-to-Stand Lift During Resident Transfer
Penalty
Summary
The facility failed to follow manufacturer guidance during the transfer of a resident using a sit-to-stand lift. Resident #14, who has severe cognitive impairment and is dependent on staff for activities of daily living, was transferred from a wheelchair to a bed and back without using the required buttock strap. The resident's left hand, which cannot fully open, was forcibly placed on the handle by a CNA, and the resident's body was not properly supported during the transfer. This method of transfer was observed to be unsafe and not in compliance with the manufacturer's instructions, which mandate the use of a buttock strap for safety and comfort. The Director of Nursing and Assistant Director of Nursing both acknowledged that staff should follow manufacturer safety guidelines when operating the lift. Despite this, the CNAs involved did not adhere to these guidelines, putting the resident at risk. The facility's training checklist for the lift was also found to be non-specific, potentially contributing to the improper use of the equipment. This deficiency has the potential to affect other residents who require similar transfers using the sit-to-stand lift.
Failure to Follow Physician Orders for Peg Tube Flushes
Penalty
Summary
The facility failed to ensure that a resident's peg tube was flushed with the appropriate amount of water as ordered by the physician. Specifically, the physician's order required the peg tube to be flushed with 60 cc of water before and after medication administration. However, an LPN was observed flushing the tube with only 30 cc of water before and after administering medication. The LPN confirmed that the correct amount should have been 60 cc and acknowledged that insufficient water flushes could lead to complications such as improper medication absorption and failure to clear stomach contents. The Assistant Director of Nursing (ADON) confirmed that nursing staff are expected to check physician orders prior to administering medications and flushes. The ADON also acknowledged that not following the prescribed flush amount could result in the peg tube not being cleared of stomach contents, potentially causing nutritional issues. The facility had an in-service training on medication administration, but it did not provide documentation of material covered specifically related to peg tube orders, and no policies on peg tubes or medication administration were provided.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure medications were stored and labeled in accordance with state laws and accepted standards of pharmacy practice. During an observation, a medicine cup containing a solid-tubular clear substance was found on the dresser of one resident, and another medicine cup containing a solid-tubular white substance was found on the nightstand of another resident. The Director of Nursing (DON) was unable to definitively identify the substances and acknowledged that medications should not have been left in the room. Additionally, a resident self-administered nasal spray incorrectly, administering two sprays in one nostril and one spray in the other, contrary to the prescribed order of one spray in each nostril. The medication cart was also found unlocked with keys in the lock, displaying the resident's personal information on the screen, and left unattended by the LPN, which was confirmed by the DON as a safety concern. Further observations revealed that another medication cart was left unlocked and unattended by an LPN, who was seated at the nurse's station and unable to see the cart. The DON and Assistant Director of Nursing (ADON) confirmed that medication carts should be locked when unattended to prevent unauthorized access. The facility's policy on medication storage states that medications and biologicals should be stored safely, securely, and properly, and that medication supplies should be accessible only to authorized personnel. The policy also specifies that medication carts and supplies should be locked when not attended by authorized personnel.
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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