Pine Bluff Transitional Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Pine Bluff, Arkansas.
- Location
- 6810 South Hazel Street, Pine Bluff, Arkansas 71603
- CMS Provider Number
- 045379
- Inspections on file
- 39
- Latest survey
- January 22, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Pine Bluff Transitional Care during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment, behavioral symptoms, a history of falls, and an active PRN pain medication order returned from the hospital at night and repeatedly requested pain medication for head pain. A CNA reported the requests multiple times to the only LPN on duty, who had the keys to all med carts, but the LPN did not assess the resident on that hall or administer any pain medication, stating that another LPN (who was not present or on the staffing log) was supposed to pass meds there. Review of the eMAR and staffing records confirmed that no pain medication was given during this period despite the resident’s repeated requests and an active PRN order, constituting a failure to provide ordered and requested pain management.
The facility did not have a full-time DON for about a month, leaving the position vacant and disrupting the chain of command among nursing staff. Staff reported increased stress and uncertainty due to the lack of clinical leadership, and documentation confirmed the vacancy and ongoing efforts to fill the role.
A CNA failed to change gloves and perform hand hygiene during incontinence care for a dependent resident with severe cognitive impairment. The CNA handled clean items and applied cream to the resident's perineal area while wearing contaminated gloves, contrary to facility protocols and infection control policies. Staff interviews confirmed that proper hand hygiene and glove changes were expected but not performed in this instance.
A resident with severe cognitive impairment and psychiatric diagnoses alleged being physically abused by a staff member. Although the allegation was reported internally and investigated by the Interim Administrator, it was not reported to the State Survey Agency or other required authorities within the mandated timeframe, as required by facility policy and federal regulations.
A resident with severe mental impairment and a history of daily aggressive behaviors repeatedly initiated altercations with others, including hitting and entering other residents' rooms, without consistent documentation of interventions or provider notification. Staff were aware of the risks but sometimes left the resident unattended, and standing orders did not address aggression. A behavioral health evaluation was not completed as ordered, and required follow-up for affected residents was often missing.
A resident with a history of wandering and delusional behaviors was able to exit the facility multiple times due to malfunctioning secured unit doors, inconsistent use of a wander guard, and inadequate alarm systems. Staff and maintenance were aware of these issues, and a gate code was posted in plain sight, further compromising security. Despite care plans and physician orders, effective interventions to prevent elopement were not implemented, resulting in repeated incidents where the resident left the premises.
The facility did not consistently provide enough nursing staff to meet the needs of all residents, as evidenced by discrepancies between staffing logs and actual staff present, frequent instances of CNAs working alone on halls, and the absence of a DON for an extended period. Staff interviews confirmed that these shortages led to missed showers, incomplete treatments, and concerns about resident safety.
The facility did not report a resident elopement that required police involvement, nor did it report multiple resident-to-resident altercations, including one that resulted in injury. These incidents involved residents with cognitive impairment and behavioral issues, and were not communicated to the State Survey Agency as required by facility policy.
Two residents with pressure ulcers or at risk for pressure ulcers did not receive wound care as ordered by physicians, with incomplete or missing documentation on the TAR and inconsistent weekly skin assessments. Staff interviews confirmed that wound care was likely not performed if not documented, and leadership attributed the deficiencies to inadequate staffing.
The facility was found to have significant sanitation and food safety deficiencies, including the presence of pests, improper food storage, and inadequate hand hygiene practices. Roaches were observed in the kitchen, and food items were not stored according to professional standards, with expired products not discarded. Staff failed to maintain proper hand hygiene, and food temperatures were not kept within safe ranges, posing potential health risks to residents.
The facility did not develop or implement a current facility-wide assessment to determine necessary resources for resident care. The Administrator, in her role since late 2023, acknowledged responsibility but could not explain the absence of the assessment. An outdated tool from 2017 was provided, lacking relevant information.
The facility did not consistently implement its antibiotic stewardship program for a resident on Doxycycline for a skin infection. The Nurse Consultant updated infection control logs but lacked information for October. The ADON provided reports for June to September, missing critical tracking details. The resident's medication order lacked a specified duration or stop date, contrary to the facility's policy requiring complete antibiotic orders.
The facility did not designate a qualified Infection Preventionist (IP) to manage the infection prevention and control program. Documentation showed the absence of an IP, and no infection control trainings were conducted from October 2023 to October 2024. The Administrator acknowledged the lack of a designated IP, and the facility's policy outlined unfulfilled responsibilities due to this absence.
The facility failed to provide a pneumococcal vaccine to a resident and did not document education after another resident declined the influenza vaccine. The first resident's records lacked documentation of consent or refusal for the pneumococcal vaccine, while the second resident's records did not include the date of influenza vaccine refusal or documentation of education provided.
The facility failed to address pharmacist recommendations for psychotropic medication management for three residents. A resident with bipolar disorder had an unaddressed recommendation for Trazodone dose reduction. Another resident with catatonic schizophrenia had a PRN Haloperidol order that required re-evaluation, which was not addressed. Additionally, a resident with a psychotic disorder had multiple psychotropic medications with unaddressed dose reduction recommendations. The facility did not follow its policy on tapering medications and gradual dose reduction.
A facility's medication error rate reached 24.14% due to multiple administration errors by an RN and an LPN. Errors included early administration of Albuterol, withholding Carvedilol without parameters, and late administration of Phenobarbital, Apixaban, Metoprolol Tartrate, and Gabapentin. The facility's policy defines medication errors as deviations from physician's orders or accepted standards.
The facility failed to prepare and serve meals according to the planned menu, impacting residents' nutritional needs. Observations showed dietary staff used incorrect ingredients and portion sizes, serving 1.4 ounces of ham instead of the required 3 ounces, and using black-eyed peas instead of lima beans. These actions led to insufficient servings and deviation from the menu.
The facility failed to ensure pureed foods were blended to a smooth, lump-free consistency for residents on pureed diets. Observations revealed that black-eyed peas, turnip greens, ham, and cornbread were not adequately pureed, resulting in inconsistent textures. A dietary aide confirmed the inadequacies, noting that the foods were either mushy, watery, or thick with visible pieces.
The facility failed to report and investigate incidents of injury of unknown source for two residents within the required timeframe. One resident sustained a fractured mandible from an unwitnessed fall, while another resident rolled out of bed, resulting in a facial abrasion. The facility did not adhere to its policy requiring immediate reporting and investigation of such incidents.
The facility failed to investigate incidents of injury for two residents. One resident was found with a fractured mandible after an unwitnessed fall, and no investigation was conducted. Another resident rolled out of bed, sustaining a facial abrasion, but the incident was not reported or investigated. The facility did not adhere to its policies on incident investigation and reporting.
A resident with a tracheostomy complication did not receive care as ordered, with observations revealing improper infection control practices by an LPN. The LPN failed to sanitize hands, use sterile gloves, or wear PPE during tracheostomy care. The obturator was not replaced despite visible contamination, and necessary supplies were not stored correctly. Interviews confirmed these deficiencies, highlighting a failure to adhere to the facility's tracheostomy care policy.
The facility did not maintain full-time DON coverage, with no DON or interim DON from August 10 to August 18, 2024. Check stubs showed inconsistent full-time hours for the DON, and the administrator admitted to occasional lack of coverage. The facility's staffing policy required sufficient skilled staff for resident care.
The facility did not post daily staffing information visibly for residents and visitors, as required by policy. A surveyor noted the absence of a visible posting and a tally of actual hours worked per shift. An LPN was unaware of the requirement to include specific details in the posting. The Administrator confirmed the lack of a complete daily staffing posting. The facility's policy mandates posting daily staffing details, including the facility name, date, census, and staff categories.
A facility failed to accurately account for a controlled medication for a resident with bipolar disorder, leading to discrepancies in the narcotic log for Clonazepam. Additionally, another resident with hypertension received an incorrect dosage of Nifedipine ER due to a pharmacy error, which was not corrected before the resident's discharge. The errors were confirmed by the Nurse Consultant and ADON, highlighting a failure to adhere to the facility's medication administration policies.
The facility failed to maintain privacy for two residents during care procedures. An LPN left a resident's door open while performing tracheostomy care, violating privacy. Another resident's catheter bag was visible without a privacy bag, contrary to their care plan. The ADON confirmed these actions breached the facility's policy on resident dignity and privacy.
The facility failed to transmit accurate and complete MDS assessments to CMS within the required 14-day timeframe for two residents. One resident's assessments were exported but not accepted, and the facility lacked an MDS Coordinator, contributing to the delay. Another resident's admission record showed multiple diagnoses, but the facility's policy did not address MDS completion timeliness. The facility experienced turnover in the MDS Coordinator position and relied on external assistance to complete assessments.
The facility failed to follow physician's orders for a resident with a wound, as weekly skin evaluations were not completed. The resident's wound was initially documented as a diabetic ulcer but later identified as a pressure ulcer. Additionally, another resident's MDS inaccurately classified Risperdal as an anti-anxiety medication instead of an antipsychotic, despite the resident's diagnosis of a psychotic disorder. The DON confirmed the medication should have been documented as an antipsychotic.
The facility failed to develop comprehensive care plans for residents, leading to unmet needs in personal hygiene and physical care. A resident's care plan lacked ADL requirements, resulting in inconsistent grooming. Another resident's care plan did not address a flaccid arm and contracted hand, with no interventions observed. Additionally, a resident's care plan inaccurately noted contractures, while their legs were locked straight. These deficiencies highlight the facility's failure to address residents' individualized care needs.
The facility failed to update care plans for three residents, leading to unaddressed care needs. A resident with severe cognitive impairment was transferred using a mechanical lift without proper assistance, and their care plan lacked details on high-risk medications. Another resident's care plan did not include necessary information on anticoagulants and insulin, while a third resident's care plan failed to reflect a diabetic foot ulcer. The ADON confirmed these oversights.
The facility failed to maintain proper hygiene and grooming for three residents, leading to deficiencies in care. A resident with cerebral palsy and glaucoma was repeatedly observed with facial hair despite being dependent on staff for personal hygiene. Another resident, also dependent on staff, was found unshaved, and their care plan lacked specific ADL care. Additionally, a resident with severe cognitive impairments did not receive regular scheduled baths, with only six baths recorded over two months. Staff interviews confirmed these lapses in maintaining residents' hygiene and dignity.
The facility failed to conduct weekly skin evaluations for several residents as ordered, and did not provide appropriate treatment for a resident with a contracture. One resident had an open wound on their leg, but skin assessments were not performed weekly. Additionally, a resident with a flaccid arm and contracted hand did not have a device to prevent further decline, and their care plan did not address these issues.
A facility failed to properly use a mechanical lift for a cognitively impaired resident with physical limitations, as the care plan lacked specific transfer instructions. A CNA used the lift without assistance, violating policy. Additionally, a resident with severe cognitive impairment and respiratory issues was not assessed for smoking safety and was observed smoking without a protective apron. Staff confirmed the absence of required assessments and adherence to safety protocols.
Two residents received improper incontinence care, leading to potential health risks. A resident with cognitive impairment was found with a wet ring around the buttock area, and a CNA failed to clean the entire genital area after an incontinence episode. Another resident, who was cognitively intact, was improperly cleaned with a back-and-forth motion, risking infection. The facility's administrator acknowledged these issues, emphasizing the importance of proper cleaning to prevent infections.
The facility failed to implement enhanced barrier precautions for a resident with a PEG tube, lacked a comprehensive water management program, and demonstrated poor infection control practices. Observations revealed improper handling of laundry, inadequate PPE use, and lapses in hand hygiene during resident care, leading to potential cross-contamination. Additionally, tracheostomy care was not performed according to policy, with issues in sterile technique and PPE use.
A resident with a PEG tube was not properly managed as the facility failed to check tube placement before administering fluids and medications, and did not follow the physician's order for the enteral feeding rate. The feeding rate was set at 95 ml/hr instead of the prescribed 90 ml/hr, and the feeding bottle lacked necessary labeling information. A nurse admitted to not receiving training on checking tube placement, contributing to the deficiency.
A facility failed to ensure a resident with impaired cognitive function and a history of suicidal ideation was safe to self-administer medications. The resident's care plan required medication administration and monitoring, yet over-the-counter medications were found in the resident's bathroom. The Nurse Consultant and Administrator confirmed that the resident was not assessed for self-administration, and facility policy requires an interdisciplinary team assessment for such authorization.
The facility did not ensure residents received mail on Saturdays, violating their right to prompt mail delivery. The Activity Director only delivers mail Monday through Friday, and the Administration confirmed no mail delivery occurs on Saturdays, contrary to the facility's Resident Rights policy.
A facility failed to complete Monthly Medication Regimen Reviews (MMR) for a resident with moderate cognitive impairment who was on high-risk medications for depression, anxiety, and fluid retention. The facility's Administrator could not provide documentation to prove that MMRs were conducted, despite a policy requiring monthly reviews by the Consultant Pharmacy.
A facility failed to notify the Ombudsman of a resident's hospital transfer. The resident, diagnosed with catatonic schizophrenia and severely cognitively impaired, was sent to a hospital due to decreased LOC. Although the resident's relative was informed, the Ombudsman was not notified. The ADON indicated that Social Services was responsible for this task, but it was not communicated clearly, leading to the oversight.
The facility failed to complete timely MDS assessments for a resident, lacking both Admission and Quarterly MDS. Staffing challenges contributed to this oversight, with two RNs resigning shortly after hire and an LPN from a sister facility assisting. An RN was contracted to perform MDS tasks remotely.
A facility failed to conduct weekly skin evaluations for a resident with a stage 3 wound on the left big toe, as ordered by the physician. The resident's wound was initially documented as a diabetic foot ulcer but later reclassified as a pressure ulcer. Despite the care plan highlighting the need for preventive measures due to fragile skin, no evaluations were conducted between August and October, as confirmed by interviews with facility staff.
Two residents with severe cognitive impairment did not receive proper wound care as per physician orders, leading to deficiencies in pressure ulcer management. Dressings were not changed as required, and there was confusion among staff regarding responsibility and access to supplies. The facility lacked a wound care policy, contributing to inconsistent care and monitoring.
The facility failed to employ a full-time DON. The Administrator confirmed that the facility had been without a DON since March 2024 and lacked a policy for DON coverage.
The facility failed to maintain an effective pest control program, resulting in flies and roaches being present in the kitchen, dining room, resident rooms, and hallways. Observations and staff interviews confirmed the widespread issue, despite the facility having a pest control contract.
A facility failed to complete a discharge summary for a resident with type 2 diabetes and diabetic peripheral angiopathy with gangrene. The resident, who was cognitively intact and required maximum assistance with ADLs, was discharged without a discharge summary in their medical records. Interviews revealed that nurses are responsible for completing discharge summaries, but the facility lacks a discharge policy.
A resident with unspecified protein-calorie malnutrition and severe cognitive impairment was not served a meal in a timely manner, despite being seated at the feed assist table. Interviews with staff, including the Dietary Manager and ADON, revealed no clear reason for the oversight. The facility lacked a policy on timely meal service.
The facility failed to secure smoking materials and provide adequate supervision during smoke breaks, leading to a resident with Dementia and COPD having unsupervised access to cigarettes and a lighter. Staff interviews revealed inconsistencies in supervision and storage of smoking materials, contrary to the facility's smoking policy.
Failure to Provide PRN Pain Medication After Resident’s Return From Hospital
Penalty
Summary
The deficiency involves the facility’s failure to provide prescribed and requested PRN pain medication to a resident following a return from the hospital. The resident had been admitted with diagnoses including bipolar disorder, current episode manic severe with psychotic features, and had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. The resident’s MDS documented verbal behavioral symptoms directed toward others, dependence for toileting/personal hygiene, a history of multiple falls, and use of high‑risk medications including antianxiety agents, antidepressants, opioids, and anticonvulsants. The care plan, revised in late February, identified a behavior problem of agitation related to communication, including that the resident would throw themself on the floor if verbalized demands were not instantly met, and also identified a risk for pain with an intervention to anticipate the resident’s need for pain relief and respond immediately to any complaint of pain. The eMAR for January showed an active PRN pain medication order to give one tablet orally every four hours as needed for pain, with ongoing pain monitoring orders. On the night in question, the resident returned from the hospital around 10:30 PM. After being put to bed, the resident requested pain medication for head pain. CNA staff reported informing an LPN that the resident was requesting pain medication. The CNA later stated that around 12:30 AM, the resident continued calling out for help and reporting pain, and the CNA again went to the nurse. The CNA further reported that around 5:00 AM, the resident was still awake and asking for medication for head pain, and the CNA again approached the same LPN, who refused to administer pain medication, stating that another LPN, who was not present in the building, had agreed to pass medications on that hall. The CNA stated that the LPN did not go to the resident’s room at all during the shift and did not provide any pain medication despite multiple requests relayed by the CNA. Documentation and interviews showed that the LPN on duty had accepted the keys to all medication carts and was the only nurse listed on the staffing log for that night, with no timecard entries indicating that the other LPN was working or present. The LPN’s own witness statement indicated they signed for the resident’s return from the hospital and that a co‑worker handled all medications for the hall where the resident resided, and that they rarely appeared on that hall. However, the daily staffing log and timecard records showed no other LPN assigned or clocked in after an earlier date. The DON and another LPN stated that the nurse who accepts the keys to all medication carts and is the only nurse in the building is responsible for addressing any resident’s request for medication, including pain medication. Review of the MAR during the facility’s investigation confirmed that no pain medication was administered to the resident during the period when the resident repeatedly requested it after returning from the hospital. Additional interviews supported that the resident was distressed the following morning. Social Services reported finding the resident lying on a mat on the floor the morning after the incident, with the resident voicing being mad, though not specifying the reason. The Administrator stated that there was no written communication from the LPN about what was occurring in the resident’s room and that the LPN did not always communicate back with administration. Facility policies on administering medications required that medications be administered in a safe and timely manner as prescribed, and the Abuse Prevention Program policy required the administration to protect residents from abuse and neglect. The Office of Long‑Term Care Incident and Accident report categorized the event as abuse and neglect, noting that the resident was sent to the hospital after a fall and, upon return, requested pain medication twice with no medication provided, and that the alleged perpetrator was a facility employee.
Failure to Maintain Full-Time Director of Nursing
Penalty
Summary
The facility failed to ensure the presence of a full-time Director of Nursing (DON), as required by regulations, which affected all 60 residents. Record review showed that the DON position was documented as vacant in the Facility Assessment. Interviews with the Administrator and the Vice President of Operations confirmed that the facility had not had a DON for approximately one month, and there were no nursing waivers in place. The Administrator was unable to specify when the previous DON left, and documentation showed that the position had been posted for hire since early May. Staff interviews revealed that the absence of a DON disrupted the chain of command among nursing staff. The Medical Records Nurse indicated that the lack of a DON had broken the chain of command for floor staff, and an LPN described the situation as stressful due to uncertainty in the absence of leadership. The DON job description outlined responsibilities including directing nursing services, care planning, and administrative functions, all of which were unfulfilled during the vacancy.
Failure to Perform Hand Hygiene and Change Gloves During Incontinence Care
Penalty
Summary
During an observation, a Certified Nursing Assistant (CNA) was seen performing incontinence care for a resident with severe cognitive impairment and total dependence on staff for personal care. The CNA initially performed hand hygiene and donned gloves, but after removing the resident's soiled brief, the CNA, while still wearing the same contaminated gloves, searched through the resident's bedside drawer and dresser to retrieve a tube of cream. The CNA then applied the cream to the resident's perineal area and placed a clean brief on the resident, continuing to wear the same gloves throughout these tasks. The CNA also repositioned the resident and handled clean linens without changing gloves or performing additional hand hygiene. Interviews with the CNA and an LPN confirmed that hand hygiene and glove changes should have occurred when moving from dirty to clean tasks and when touching the resident's environment. Facility policy and protocols reviewed indicated that staff were trained to avoid touching clean items or surfaces with soiled gloves and to perform hand hygiene when moving between contaminated and clean body sites. The failure to follow these procedures was directly observed and acknowledged by staff and facility leadership.
Failure to Timely Report Alleged Physical Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse involving a resident to the State Survey Agency within the required two-hour timeframe. On 06/05/2025, a CNA reported to an LPN that a resident, who had severe cognitive impairment and multiple psychiatric diagnoses, alleged being punched in the genital area by a night shift staff member. The LPN assessed the resident, who reported soreness, and notified the Interim Administrator. However, there was no documentation that the State Survey Agency, medical provider, family, or law enforcement were notified of the allegation as required. The Interim Administrator conducted an internal investigation, including interviews with staff and the resident, but did not report the allegation externally because the resident's account was inconsistent and the administrator believed the claim could not be substantiated. The facility's abuse prevention policy required reporting all allegations of abuse within federal timeframes, but the administrator did not follow this procedure. The lack of timely reporting was confirmed through record review, interviews, and policy review, and no further documentation of required notifications was provided.
Failure to Protect Residents from Abuse Due to Inadequate Behavioral Interventions
Penalty
Summary
The facility failed to protect residents on the secure unit from abuse by not developing and implementing effective interventions for a resident with a history of aggressive behaviors. This resident, who was severely mentally impaired and had diagnoses including seizure disorder, traumatic brain injury, psychotic disorder, and schizophrenia, exhibited daily physical behavioral symptoms such as hitting, kicking, pushing, and wandering. Multiple documented incidents showed the resident initiating altercations with other residents, including hitting, knocking down, and jumping on others, often without adequate follow-up or assessment of the affected residents. Staff did not consistently document interventions or notify providers after these altercations, despite facility policy requiring such actions. In several cases, there was no record of assessment or status for the recipients of the altercations, and provider notification was missing for specific incidents. Interviews with staff revealed a general awareness of the resident's aggressive tendencies, but also indicated that staff were sometimes left alone on the unit, resulting in the resident being left unattended and able to enter other residents' rooms unsupervised. Additionally, standing orders provided to staff did not address agitation or aggression, and a behavioral health evaluation ordered for the resident had not been completed due to leadership and resource issues. The lack of timely provider notification, incomplete documentation of interventions, and failure to implement effective behavioral management strategies contributed to repeated altercations and placed all residents on the secure unit at risk.
Failure to Maintain Secured Unit Doors and Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to ensure that entrance and exit doors to the secured unit were functioning properly, resulting in the inability to safeguard residents and prevent elopement. Multiple observations and interviews revealed that a resident with a history of wandering and elopement risk was able to exit the facility on several occasions, including through a window and various doors. The resident was known to have delusional behaviors and was assessed as being at risk for elopement, with care plans and physician orders specifying the use of a wander guard and regular checks for its placement and function. However, documentation and staff interviews confirmed that the wander guard was not consistently in place, and there were periods when no replacement was available after it was lost. Facility records and staff statements indicated that exit doors and alarms were not consistently operational. Some doors did not alarm as intended, and in one instance, the alarm was so faint it could barely be heard. The front door, which was supposed to alarm when a wander guard was near, was reported to have malfunctioned, and the resident was able to exit. Additionally, a piece of paper with the gate code was posted next to an exit door, making it accessible to residents who could read, further compromising security. Maintenance staff acknowledged ongoing issues with door functionality and a lack of monitoring while repairs were pending. Staff interviews revealed that the resident had eloped multiple times, sometimes requiring law enforcement intervention to locate and return the resident. The resident was moved off the secured unit despite ongoing behavioral concerns and a history of elopement. Staff also reported that leadership was aware of the malfunctioning doors and alarms but did not implement effective interventions to prevent further incidents. There was no pertinent information in the facility's policy to support adequate prevention of elopement, and the administrator admitted that effective interventions were not in place to prevent the resident from leaving the facility.
Failure to Provide Sufficient Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff each day to meet the needs of every resident, as required by regulation. Multiple reviews of daily staffing logs and corresponding time sheets over a three-month period revealed frequent discrepancies between the facility's reported staffing levels and the actual number of staff present. On numerous occasions, the number of staff working was less than what was documented on the staffing logs and below the facility's own minimum staffing plan, as outlined in the facility assessment. These discrepancies affected all shifts, including day, evening, and night, and occurred while the facility census ranged from 62 to 68 residents. Interviews with staff and administration further confirmed the staffing shortages. Several CNAs reported working alone on their assigned halls, which prevented them from providing scheduled showers or ensuring resident safety when attending to other residents. One CNA stated she worked alone on the hall three to four times a month and could not provide showers under those circumstances. Another CNA expressed concern about being unable to monitor residents for safety, especially when caring for one resident left others unsupervised. An LPN reported being responsible for two halls and wound care, indicating an excessive workload due to insufficient staffing. The Maintenance Director also noted that there should always be two staff members on the secured unit, but this was not consistently the case. The facility was also without a Director of Nursing (DON) for nearly a month, as confirmed by the Administrator, which further contributed to the staffing challenges. The Administrator acknowledged that the facility did not have enough staff and identified staffing as the root cause of issues such as elopements, incomplete treatments, and missed showers. The facility's own policy stated that sufficient numbers of staff with the necessary skills and competency would be provided to meet all residents' needs, but this was not consistently achieved during the period reviewed.
Failure to Report Elopement and Resident-to-Resident Altercations
Penalty
Summary
The facility failed to report several significant incidents to the State Survey Agency as required by both facility policy and regulatory standards. Specifically, an elopement involving a cognitively intact resident with a history of wandering and delusional behaviors was not reported. The resident exited the facility, evaded staff supervision, and entered nearby woods, prompting a police search with dogs. Despite the seriousness of the event and the involvement of law enforcement, the incident was not reported to the appropriate authorities. Additionally, the facility did not report multiple resident-to-resident altercations, some resulting in injury or with the potential to cause injury. One resident with severe cognitive impairment and a history of physical aggression was involved in several altercations, including an incident where another resident was punched in the face, resulting in a busted lip. Other altercations involved residents being hit or jumped on, though no injuries were recorded in those cases. These incidents were documented internally but not reported externally as required. Interviews with the facility Administrator confirmed that these incidents were not reported to the State Survey Agency, despite facility policies mandating immediate reporting of abuse, neglect, and altercations. The facility's own policies specify that all such incidents, including resident-to-resident altercations, must be reported to the appropriate agencies. No additional documentation or evidence of reporting was provided by the facility during the survey.
Failure to Follow Physician Orders for Wound Care and Documentation
Penalty
Summary
The facility failed to ensure that physician's orders for wound care were followed for two residents with pressure ulcers or at risk for pressure ulcers. For one resident with diabetes and moderate cognitive impairment, documentation showed no current skin issues, but a podiatry visit identified a stage 3 pressure ulcer on the left great toe. Despite orders for daily wound care to the right great toe, there was no evidence on the Treatment Administration Record (TAR) that any dressing changes were completed, and the wound was actually on the left foot. Observations confirmed the presence of a dressing on the left foot, and staff interviews indicated that if wound care was not documented on the TAR, it was likely not performed. Weekly skin assessments were also not up to date. For another resident with moderately impaired cognition and two stage 4 pressure ulcers, care plans and physician orders required daily wound care to the sacrum-coccyx area and scrotum. Review of the TAR revealed that wound care was only documented as completed on 16 of 31 days in one month and 7 of 14 days in the following month. Staff interviews confirmed that wound care was not completed daily as ordered, and weekly skin evaluations were inconsistently performed depending on staff availability. The Director of Nursing and Administrator acknowledged that the lack of documentation and incomplete wound care was due to inadequate staffing, which resulted in missed treatments and outdated skin assessments. There was no information in the facility's policies to support the deficient practice.
Sanitation and Food Safety Deficiencies
Penalty
Summary
The facility failed to maintain a sanitary and pest-free kitchen environment, as evidenced by the presence of roaches near the handwashing and food preparation sinks. The kitchen floor and equipment, such as the oven and grill, were observed to have accumulations of grease and food crumbs. Additionally, food items were improperly stored, with an opened bottle of grape jelly left unrefrigerated against manufacturer's instructions. In the walk-in refrigerator, several food items were improperly stored and expired products were not discarded. Diced tomatoes showed signs of spoilage, and leftover pasta sauce was stored beyond the recommended three-day period. Expired dairy products, such as cottage cheese and sour cream, were found, and bread products were not kept frozen as required. In the freezer, multiple opened boxes of food items were not covered or sealed, and expired marinara sauce was found. Similar issues were noted in the storage room, with opened and unsealed bags of grits, oatmeal, salt, and rice. The facility also failed to maintain proper hand hygiene and food temperature standards. Staff members were observed contaminating their hands after washing and then handling clean equipment without re-washing. Food temperatures were not maintained within safe ranges, with steak fingers and egg salad sandwiches found at unsafe temperatures. The ice machine was found with a slimy residue, indicating inadequate cleaning. These deficiencies highlight significant lapses in food safety and hygiene practices within the facility.
Failure to Implement Facility-Wide Assessment
Penalty
Summary
The facility failed to develop and implement a comprehensive facility-wide assessment, which is necessary to determine the resources required to care for residents competently during both day-to-day operations and emergencies. Upon the survey team's entry on 10/07/2024, the Administrator provided documents for review, but a facility assessment was not included. On 10/11/2024, the Nurse Consultant was informed of the need for the facility assessment, but it was revealed that the facility did not have one in place. During an interview on 10/14/2024, the Administrator, who assumed her role on 11/23/2023, acknowledged her responsibility for completing the assessment but could not explain why it had not been done. The Assistant Director of Nursing later provided an outdated Facility Assessment Tool from 2017, which contained no relevant information for the current facility needs.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to consistently implement its antibiotic stewardship program for a resident who was taking an antibiotic. The Nurse Consultant, who had been at the facility for only a few days, managed to catch up on four months of infection control tracking logs but did not provide information for October 2024. The Assistant Director of Nursing provided antibiotic stewardship infection mapping and an Order Listing Report for June to September 2024, which lacked a tracking log indicating the resident's signs/symptoms, the start date of symptoms, whether lab tests were required, and criteria for antibiotic necessity. The September Order Listing Report showed that a resident was taking Doxycycline for a skin infection without a specified duration of therapy or stop date. The facility's Antibiotic Stewardship policy, revised in December 2016, required complete antibiotic orders, including drug name, dose, frequency, duration, route, and indication for use, which was not adhered to in this case.
Failure to Designate an Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist (IP) responsible for the infection prevention and control program. Upon the survey team's entry on 10/07/2024, the Administrator provided documentation indicating the absence of an IP. Further review of the facility's in-service binder revealed no infection control trainings from October 2023 to October 14, 2024. The Assistant Director of Nursing acknowledged the lack of infection control in-services and stated she would investigate. The Administrator admitted to not designating a staff member to act as IP until a new hire was made. The facility's policy, revised in July 2016, outlined the IP's responsibilities, including coordinating infection control policies, data analysis, and staff education, none of which were being fulfilled due to the absence of a designated IP.
Deficiencies in Vaccine Administration and Documentation
Penalty
Summary
The facility failed to ensure that a pneumococcal vaccine was provided to a resident, identified as Resident #59, who was admitted on 06/22/2023. The resident's electronic health record lacked documentation indicating whether the resident consented to or declined the pneumococcal vaccine. A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/17/2024 showed that the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13, yet the pneumococcal vaccine was not offered. When questioned, the Assistant Director of Nursing (ADON) was unable to provide any information regarding the pneumococcal vaccine for this resident. Additionally, the facility did not document the education provided to another resident, identified as Resident #33, after the resident declined the influenza vaccine. The immunization screen for this resident indicated a refusal of the influenza vaccine but did not include the date of refusal. The resident's Order Summary Report confirmed a diagnosis of type 2 diabetes mellitus with hyperglycemia, and a significant change MDS with an ARD of 06/01/2024 indicated the resident was cognitively intact with a BIMS score of 14. The ADON was unable to provide documentation of the declination consent or the education provided, as the immunization screen only noted the refusal without a date.
Failure to Address Pharmacist Recommendations for Psychotropic Medications
Penalty
Summary
The facility failed to address pharmacist recommendations for psychotropic medication management for three residents. Resident #50, diagnosed with bipolar disorder, was prescribed Trazodone and had a recommendation for dose evaluation and reduction from a pharmacy medication regimen review dated 08/17/2024, which remained unaddressed by the physician as of 10/08/2024. Resident #57, with catatonic schizophrenia, had a PRN order for Haloperidol that required a 14-day stop date and physician re-evaluation, which was not addressed by 10/08/2024. The facility's policy on tapering medications and gradual dose reduction was not followed, as the necessary evaluations and adjustments were not made. Resident #8, with a diagnosis of a psychotic disorder, was on multiple psychotropic medications, including Risperidone, Mirtazapine, and Duloxetine, since 12/2023. A recommendation for dose evaluation and reduction was noted on 07/28/2024 and 08/18/2024, but the medical director did not provide a rationale for not attempting a gradual dose reduction. The administrator confirmed that the suggestion for a gradual dose reduction for Resident #8's Risperdal was not addressed or attempted, indicating a lapse in following the facility's policy and addressing pharmacist recommendations.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 24.14% during an observation of medication administration involving four residents. The errors were identified during the administration of medications by one RN and one LPN. For Resident #36, the RN administered Albuterol inhalation 90 mcg two hours early and withheld Carvedilol without notifying the provider, despite no parameters being indicated for withholding the medication. Additionally, the RN omitted Zinc Gluconate for Resident #31 because Zinc Sulfate was available instead, and the order was later changed to Zinc Sulfate after consultation with a Nurse Practitioner. Further errors were observed with Resident #37, where Phenobarbital was administered two and a half hours late by the LPN. For Resident #54, the LPN administered Apixaban, Metoprolol Tartrate, and Gabapentin three hours late, disrupting the scheduled medication times. The facility's policy on medication errors, revised in April 2014, defines such errors as deviations from physician's orders, manufacturer's specifications, or accepted professional standards, including wrong drug administration and incorrect timing.
Failure to Adhere to Planned Menu and Portion Sizes
Penalty
Summary
The facility failed to ensure that meals were prepared and served according to the planned written menu, which was intended to meet the nutritional needs of the residents. During an observation, it was noted that the dietary staff used a 4-ounce spoon to puree black-eyed peas instead of the lima beans specified on the menu. Additionally, the dietary staff incorrectly calculated the number of servings needed for pureed ham, resulting in insufficient portions being prepared. Specifically, 30 small pieces of ham were used to make 3 servings, although 4 servings were required, and 60 pieces were used to make 6 servings when 13 were needed. Further observations revealed that residents on regular diets received only 1.4 ounces of ham instead of the 3 ounces specified in the menu. The dietary staff also added extra bread to the pureed meat mixture, which was not part of the planned menu. These discrepancies indicate a failure to adhere to the menu, potentially compromising the nutritional intake of the residents. The dietary staff's actions and inactions led to the deficiency, as they did not follow the planned menu or ensure the correct portion sizes were served.
Inadequate Preparation of Pureed Foods
Penalty
Summary
The facility failed to ensure that pureed food items were blended to a smooth, lump-free consistency for residents requiring pureed diets. During an observation, it was noted that the dietary staff used a 4-ounce spoon to place black-eyed peas into a blender, which were then pureed and poured into a pan. The consistency of the pureed black-eyed peas was described as mushy and not formed. Similarly, turnip greens were pureed and placed in a pan, resulting in a watery consistency that was not formed. Additionally, small pieces of ham, dinner rolls, and bread were blended with broth, but the resulting mixture was thick with visible pieces of ham skins. Further observations revealed that hot water cornbread was pureed with milk, resulting in a thick consistency. During an interview, a dietary aide confirmed that the pureed turnip greens were not smooth, the black-eyed peas resembled a milkshake, the pureed ham was thick like mashed potatoes with skin, and the pureed cornbread appeared like raw dough. These findings indicate that the facility did not adequately prepare pureed foods to meet the dietary needs of residents, potentially increasing the risk of choking or other complications.
Failure to Report and Investigate Injuries of Unknown Source
Penalty
Summary
The facility failed to report an incident of injury of unknown source to the Administrator within the required 2-hour timeframe, leading to a delay in initiating an investigation and protective measures. This deficiency involved two residents. The first resident was found on the floor with a cut to the forehead and was later diagnosed with a fractured mandible. Despite the severity of the injury, the incident was not reported to the Administrator or documented in an Incident and Accident Report, as confirmed by interviews with the Administrator and Nurse Consultant. The second resident, who had multiple medical conditions including dementia and muscle wasting, rolled out of bed onto a fall mat, sustaining a facial abrasion. The resident was sent to the hospital for evaluation, but the Administrator was not aware of the incident and did not have any reportables for the month. This lack of reporting was contrary to the facility's policy, which mandates prompt reporting and investigation of such incidents. The facility's policy requires that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, be reported immediately, but no later than two hours if serious bodily injury is involved. The policy also outlines the roles and responsibilities of the Administrator in ensuring investigations are conducted and reported to the appropriate agencies. However, in these cases, the facility did not adhere to its own policies, resulting in a failure to report and investigate the incidents in a timely manner.
Failure to Investigate Resident Injuries
Penalty
Summary
The facility failed to ensure that an incident involving an injury of unknown origin was immediately and thoroughly investigated, as evidenced by the case of Resident #50. On 7/13/2024, Resident #50 was found on the floor with a cut to the forehead and was referred to the hospital for observation. The following day, the hospital informed the facility that x-ray results showed a fractured mandible, necessitating a soft foods diet and follow-up with an ENT specialist. Despite these findings, the facility did not conduct an investigation into the unwitnessed fall that resulted in a major injury. Interviews with the Administrator and Nurse Consultant confirmed the absence of an investigation and analysis (I&A) report for this incident. Another deficiency was identified in the case of Resident #59, who was admitted with multiple diagnoses, including amputated toes, difficulty in walking, and dementia. On 9/25/2024, Resident #59 rolled out of bed onto a fall mat, sustaining a 2 cm abrasion across the right eyebrow and was sent to the hospital for evaluation. Despite the severity of the incident, the Administrator did not have any reportable incidents for September and did not acknowledge awareness of Resident #59's fall and subsequent hospital transfer. The facility's policies on Abuse Investigation and Reporting, as well as Accidents and Incidents - Investigating and Reporting, require that all incidents be promptly reported and thoroughly investigated. The Administrator is responsible for assigning investigations and ensuring protective measures are in place. However, in both cases, the facility failed to adhere to these policies, resulting in a lack of investigation and documentation for significant resident injuries.
Deficient Tracheostomy Care and Infection Control Practices
Penalty
Summary
The facility failed to provide appropriate tracheostomy care for a resident, as observed by a surveyor. The resident, who had a tracheostomy complication diagnosis, was found with light brown gauze around the tracheostomy site, indicating dried blood. The resident confirmed that the gauze had not been changed regularly. The physician's orders required tracheostomy care every 24 hours and as needed, but the care was not consistently documented or performed according to the Treatment Administration Record (TAR). Additionally, the facility's procedure for tracheostomy care was not followed, as the care was not performed using sterile techniques, and necessary supplies were not readily available at the bedside. During an observation, an LPN was seen performing tracheostomy care without following proper infection control protocols. The LPN did not sanitize the bedside table before placing a sterile field, did not wear sterile gloves, and failed to sanitize hands before changing gloves. The LPN also did not use personal protective equipment (PPE) during the procedure. The obturator, which was visibly contaminated with mucus, was not replaced with a new one, and the spare obturator was not stored at the head of the resident's bed as required. The LPN admitted to not following the sterile procedure and was unable to locate the spare obturator. Interviews with the Nurse Consultant and the Assistant Director of Nursing confirmed the deficiencies in tracheostomy care and infection control practices. They acknowledged that the LPN should have sanitized hands, worn sterile gloves, and used PPE during the procedure. They also confirmed that the spare obturator should be kept at the head of the resident's bed and that tracheostomy care was not performed as ordered. The facility's policy emphasized minimizing infection risks and ensuring supplies for tracheostomy care are readily accessible, which was not adhered to in this case.
Lack of Full-Time DON Coverage
Penalty
Summary
The facility failed to ensure full-time Director of Nursing (DON) coverage, as required by regulations. From August 10, 2024, to August 18, 2024, there was no DON or interim DON employed at the facility. Additionally, check stubs provided to the surveyor on October 14, 2024, indicated that the DON did not consistently work full-time hours over a two-week period. The facility's administrator acknowledged that there were times when DON coverage was not available. The facility's staffing policy stated that sufficient numbers of staff with the necessary skills and competency should be provided to care for all residents in accordance with the facility assessment.
Failure to Post Daily Staffing Information
Penalty
Summary
The facility failed to ensure that daily staffing information was posted visibly for residents and visitors, as required by their policy. On October 10, 2024, at 9:00 AM, a surveyor observed that there was no visible posting of the daily staffing and resident census. Additionally, the sign-in sheet lacked a tally of actual hours worked per shift for direct care staff. Later that day, the facility's Staff Coordinator, an LPN, admitted to being unaware of the requirement to include the facility name, date, census, nursing staff responsible for direct care, and a tally of actual hours worked per shift in the posting. On October 14, 2024, the Administrator confirmed that the facility did not have a daily staffing posting with all the required components. The facility's policy, titled 'Posting Direct Care Daily Staffing Numbers,' mandates that such information be posted daily for each shift, including the number of nursing personnel responsible for providing direct care to residents, the facility name, date, census, category of licensed and unlicensed staff working each shift, and actual time worked for each category.
Medication Administration and Dosage Errors
Penalty
Summary
The facility failed to accurately account for a controlled medication for a resident diagnosed with bipolar disorder. The resident was prescribed Clonazepam 0.5 mg to be taken as needed for anxiety. However, discrepancies were found in the narcotic log, where Clonazepam 1 mg was documented instead of the prescribed 0.5 mg. Additionally, there was a lack of proper documentation for the administration of Clonazepam 0.5 mg, as the narcotic log did not reflect the correct dosage or administration records. The LPN responsible for the medication administration was unable to locate the correct documentation for the prescribed dosage, and the discrepancy was reported to the ADON and Administrator. Another resident with a diagnosis of Essential Hypertension was affected by a medication dosage error. The resident was prescribed Nifedipine ER 60 mg to be taken twice daily, but instead received Nifedipine ER 90 mg from the pharmacy. This error persisted from the start of the prescription until the resident's discharge, without the pharmacy being notified of the incorrect dosage. The Nurse Consultant and ADON confirmed the error, acknowledging that the resident did not receive the physician-ordered dose. The facility's policies on pharmacy services and medication orders emphasize the importance of timely and accurate medication administration, which was not adhered to in these cases.
Privacy Violations During Resident Care
Penalty
Summary
The facility failed to ensure privacy for residents during care procedures, resulting in dignity concerns. For Resident #13, who was admitted with a tracheostomy complication, the Licensed Practical Nurse (LPN) did not close the door while performing tracheostomy care. The LPN left the room to get more gauze and upon returning, continued the care with the door open, which was confirmed as a privacy violation by both the LPN and the Assistant Director of Nursing (ADON). Additionally, Resident #216, who has an indwelling catheter, was observed with the catheter collection bag hanging visibly from the side of the bed without a privacy bag. This was noted on two separate occasions, despite the resident's care plan indicating the need for the catheter bag to be positioned away from the entrance and door. The ADON confirmed that the catheter should have been in a privacy bag, aligning with the facility's policy on resident rights, which emphasizes dignity and privacy.
Failure to Timely Transmit MDS Assessments
Penalty
Summary
The facility failed to electronically transmit encoded accurate and complete Minimum Data Set (MDS) assessments to the Centers for Medicare and Medicaid Services (CMS) within the required time frame of 14 days for two residents. For one resident, the discharge return anticipated MDS and entry MDS were exported but not accepted by CMS. The resident was discharged to the hospital and later expired there. The Assistant Director of Nursing confirmed that the facility lacked an MDS Coordinator, which contributed to the failure to complete and submit the necessary assessments within the required timeframe. Another resident's admission record showed multiple diagnoses, including type 2 diabetes mellitus and schizophrenia, but the facility's policy on MDS Error Correction did not address the timeliness of MDS completion. The facility had experienced turnover in the MDS Coordinator position, with two Registered Nurses starting and resigning shortly after. The facility was relying on an LPN MDS Coordinator from a sister facility to help complete the MDS assessments and had contracted with an RN to perform MDS tasks remotely.
Failure to Follow Physician's Orders and Inaccurate MDS Assessment
Penalty
Summary
The facility failed to ensure that physician's orders were followed for a resident with a wound, as weekly skin evaluations were not completed as ordered. The resident had a stage 3 wound on the left big toe, which was initially documented as a diabetic foot ulcer but later identified as a pressure ulcer. Despite the physician's order for weekly skin evaluations, there were no evaluations recorded between August 19, 2024, and October 12, 2024. Interviews with the LPN, ADON, and Nurse Consultant confirmed the lack of weekly evaluations, which was a deviation from the physician's orders. Additionally, the facility did not accurately assess the quarterly Minimum Data Set (MDS) for another resident, as the medication Risperdal was incorrectly classified. The resident, who had a diagnosis of a psychotic disorder and moderate cognitive impairment, was taking Risperdal for psychosis. However, the care plan inaccurately reflected Risperdal as an anti-anxiety medication instead of an antipsychotic. The Director of Nursing confirmed that the medication should have been documented as an antipsychotic on the care plan and MDS.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to ensure that comprehensive care plans addressed individualized appropriate care and services for four residents. Resident #45's care plan did not include their Activities of Daily Living (ADL) requirements, despite being dependent on staff for showering and bathing. Observations showed that the resident was often unshaven and had hair on their face, indicating a lack of personal grooming care. The care plan's omission of ADL requirements led to inconsistent personal hygiene care, as evidenced by the shower log showing infrequent bathing. Resident #13's care plan did not address their flaccid right arm and contracted right hand, despite having a diagnosis of paralysis affecting the right side. Observations confirmed the absence of any device or intervention for the contracted hand, and interviews with staff confirmed the lack of care planning for these conditions. Similarly, Resident #35's care plan inaccurately noted contractures, while observations revealed that the resident's legs were locked in a straight position, unable to bend. These deficiencies highlight the facility's failure to develop and implement comprehensive, person-centered care plans that meet the residents' physical and functional needs.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to ensure care plans were revised to reflect the most recent care needs for three residents. For Resident #21, a Certified Nursing Assistant (CNA) was observed using a mechanical lift without assistance, contrary to the resident's care needs, which were not updated in the care plan. The resident had severe cognitive impairment, required substantial assistance, and was on high-risk medications, including insulin and antipsychotics, none of which were reflected in the care plan. The CNA involved was unaware of the requirement for two-person assistance with the mechanical lift. Resident #13's care plan did not address the use of anticoagulants, insulin, or the monitoring of diuretic side effects, despite the resident's severe cognitive impairment and medication regimen. Similarly, Resident #16's care plan was not updated to reflect a diabetic foot ulcer, despite ongoing assessments and progress notes indicating the presence of the wound. The Assistant Director of Nursing confirmed the oversight, acknowledging that the care plan should have been revised to include current wound care interventions.
Deficiencies in Resident Hygiene and Grooming
Penalty
Summary
The facility failed to ensure proper personal hygiene and grooming for three residents, leading to deficiencies in care. Resident #35, who has cerebral palsy and glaucoma, was observed multiple times with hair on their chin despite being dependent on staff for personal hygiene. The resident's care plan indicated a need for assistance with activities of daily living due to confusion, yet the resident was not properly groomed. Similarly, Resident #45, who is also dependent on staff for hygiene, was observed with unshaved facial hair. The care plan for Resident #45 did not include specific ADL care, indicating a lack of proper planning and execution of hygiene tasks. Additionally, Resident #32, who has severe cognitive impairments and is dependent on staff for all needs, did not receive regular scheduled baths or showers. The resident's bath schedule indicated they should receive baths three times a week, but records showed only six baths over two months. The facility's failure to adhere to the bathing schedule and ensure regular hygiene care for these residents was confirmed by staff interviews, highlighting a significant lapse in maintaining the residents' personal hygiene and dignity.
Failure to Conduct Weekly Skin Evaluations and Address Contracture
Penalty
Summary
The facility failed to ensure that residents with physician orders for weekly skin evaluations received the necessary assessments. Specifically, four residents with orders for weekly skin evaluations did not have their skin evaluated as required. For instance, one resident had a dressing on their right lower leg for an open wound, but the skin assessments were not conducted weekly as ordered. The care plan for this resident required monitoring and documentation of the skin injury, including measurements and any notable changes, but the assessments were not performed consistently. Additionally, the resident's Minimum Data Set (MDS) inaccurately documented that the resident was not at risk for pressure ulcers and had no skin problems. Furthermore, the facility did not provide appropriate treatment for a resident with a contracture. The resident had a flaccid right arm and a contracted right hand, but no device was present to prevent further decline. The care plan did not address the flaccid arm or contracted hand, and staff confirmed the absence of a device. The facility's policy on contracture treatment emphasized the importance of preventing the progression of contractures through measures such as handrolls, but these were not implemented for the resident in question.
Deficiencies in Mechanical Lift Use and Smoking Safety Assessment
Penalty
Summary
The facility failed to ensure the proper use of a mechanical lift for a resident with severe cognitive impairment and physical limitations. The resident, who had a diagnosis of joint contracture and muscle atrophy, required substantial assistance for transfers. However, the care plan did not specify the transfer method or the number of staff required. A CNA was observed using a mechanical lift to transport the resident without assistance, contrary to the facility's policy and the lift's manual, which stated that two staff members were needed for safe operation. Additionally, the facility did not assess a resident for smoking safety, despite the resident having severe cognitive impairment and a history of respiratory issues. The resident was observed smoking without a protective apron during designated smoke breaks, and there was no documented assessment of the resident's ability to smoke safely. The facility's smoking policy required an evaluation of residents' smoking habits and safety, which was not conducted for this resident. Interviews with staff confirmed the lack of proper assessments and adherence to safety protocols. The CNA involved in the lift incident was unaware of the requirement for two staff members, and both the LPN and ADON confirmed the absence of a smoking assessment for the resident. The facility's policies on safe lifting and smoking were not followed, leading to potential safety hazards for the residents involved.
Improper Incontinence Care for Two Residents
Penalty
Summary
The facility failed to provide incontinence care in a clean and sanitary manner for two residents, leading to potential health risks. Resident #33, who was cognitively intact and occasionally incontinent of bowel and bladder, was observed receiving improper cleaning from a CNA. The CNA used a back-and-forth motion with one wipe, which can spread germs and cause urinary tract infections. The CNA admitted to not being trained to wipe more than once with one wipe without folding. Resident #32, who had severe cognitive impairment and was dependent on staff for care, was found lying in bed with a wet ring around the buttock area. During incontinence care, a CNA failed to clean the entire genital area exposed to urine and potentially feces. The CNA did not clean the resident a second time after an incontinence episode, citing difficulty due to the resident's contracture. The facility's administrator acknowledged that a wet sheet indicated a lack of care and emphasized the importance of cleaning the entire genital area to prevent infections.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to consistently implement enhanced barrier precautions for a resident with a Percutaneous Endoscopic Gastrostomy (PEG) tube. During an observation, it was noted that the resident's care plan did not include instructions for using enhanced barrier precautions, and a registered nurse admitted to not wearing a gown while administering medication through the PEG tube. The nurse also could not recall receiving training on enhanced barrier precautions, and the facility was unable to provide a policy for these precautions upon request. The facility's water management program was found lacking as it did not include Legionella monitoring or a comprehensive description of the building's water system. The Maintenance Supervisor admitted to not having information on Legionella monitoring and planned to attend a meeting to gather more information. The facility's water management policy was outdated and did not align with current recommendations from the Centers for Disease Control and other relevant bodies. Infection control practices were further compromised by improper handling of laundry and inadequate use of personal protective equipment (PPE) during resident care activities. Observations revealed that laundry was transported without proper covering, and staff failed to change gloves or sanitize hands during care activities, leading to potential cross-contamination. Additionally, tracheostomy care for a resident was not performed according to the facility's policy, with lapses in hand hygiene, PPE use, and sterile technique noted during the procedure.
Deficiency in PEG Tube Management and Enteral Feeding Rate
Penalty
Summary
The facility failed to ensure proper procedures were followed for a resident with a Percutaneous Endoscopic Gastrostomy (PEG) tube. Specifically, the facility did not check the PEG tube for placement before administering fluids and medications, and did not adhere to the physician's orders regarding the enteral feeding rate. The resident, who had a diagnosis of dysphagia and required attention to a surgical opening for a feeding tube, was observed with an enteral feeding rate set at 95 ml/hr, contrary to the physician's order of 90 ml/hr. Additionally, the feeding bottle lacked the necessary information such as the time it was hung and the nurse's initials. The facility's policy on Enteral Feedings-Safety Precautions, revised in May 2014, required checking the rate of administration and ensuring the formula label included initials, date, and time. However, the policy did not specify the method for checking tube placement. During an interview, a registered nurse admitted to not receiving training on checking PEG tube placement and described using a method involving air injection and listening for a sound, which was not specified in the facility's policy. This lack of training and adherence to physician orders contributed to the deficiency in care for the resident with a PEG tube.
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident, identified as having impaired cognitive function and a history of suicidal ideation, was safe to self-administer medications. The resident's plan of care, revised on 09/11/2024, included interventions to administer medications as ordered and monitor for side effects and effectiveness. However, over-the-counter medications were observed in the resident's bathroom on multiple occasions by the surveyor, indicating that the resident had access to medications without proper assessment or authorization to self-administer. The Nurse Consultant confirmed that no residents on the hall where the resident resided were authorized to self-administer medications, and the resident had not been assessed for the ability to do so safely. The Administrator also stated that no residents in the facility were assessed to self-administer medications, and medications should not be accessible to the resident without supervision. The facility's policy on self-administration of medications requires an interdisciplinary team assessment to determine if it is clinically appropriate and safe for a resident to self-administer medications, which was not conducted in this case.
Failure to Deliver Mail on Saturdays
Penalty
Summary
The facility failed to ensure residents received mail on Saturdays, which is a violation of their right to send and receive mail promptly. During a meeting with the resident council members, it was revealed that mail is not delivered on Saturdays. The Activity Director confirmed that she only delivers mail from Monday to Friday, as these are her working days. The Administration also stated that no one is assigned to deliver mail on Saturdays. This practice is contrary to the facility's policy on Resident Rights, which stipulates that residents have the right to receive mail promptly.
Failure to Complete Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that Monthly Medication Regimens (MMR) were completed at least monthly for a resident with moderate cognitive impairment. The resident, identified as having a score of 11 on the Brief Interview of Mental Status (BIMS), was taking high-risk medications for depression, anxiety, and fluid retention. A review of the resident's plan of care, revised in May 2024, indicated the use of antidepressant medication for depression. During an interview, the facility's Administrator admitted that there was no documentation available to prove that the MMRs were completed as required. The facility's policy on Medication Regimen Reviews mandates that the Consultant Pharmacy review each resident's medication regimen at least monthly.
Failure to Notify Ombudsman of Resident's Hospital Transfer
Penalty
Summary
The facility failed to notify the Ombudsman of a resident's transfer to the hospital. The incident involved a resident with a diagnosis of catatonic schizophrenia, who was severely cognitively impaired and receiving antipsychotic medications. On August 26, 2024, the resident was sent to a local hospital due to a decreased level of consciousness, and the resident's relative was notified. The resident returned to the facility on September 5, 2024. However, the facility did not notify the Ombudsman of the transfer, as required. The Assistant Director of Nursing (ADON) stated that Social Services was responsible for notifying the Ombudsman, but it was not made clear to the responsible staff member, resulting in the notification not being completed. This oversight was identified during a review of the resident's records and an interview with the ADON on October 14, 2024.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to complete timely quarterly assessments for a resident, as required by regulations. The Minimum Data Set (MDS) for the resident showed that only an entry MDS was completed, with no Admission or Quarterly MDS conducted. The facility's policy on MDS Error Correction did not address the timeliness of completing MDS assessments. The Administrator revealed staffing challenges, with two Registered Nurses (RNs) resigning shortly after being hired, and an LPN from a sister facility assisting with MDS completion. The facility had contracted an RN to perform MDS tasks remotely. The Administrator acknowledged that the resident should have had both an Admission and a Quarterly MDS completed by this time, indicating an oversight in the process.
Failure to Conduct Weekly Skin Evaluations for Resident with Wound
Penalty
Summary
The facility failed to follow physician's orders for a resident with a wound, specifically regarding the completion of weekly skin evaluations. The resident, who had a stage 3 wound on the left big toe, was supposed to receive weekly skin assessments as per the physician's orders. However, the records show that there were no skin evaluations conducted between August 19, 2024, and October 12, 2024, despite the order for weekly assessments. This lapse in care was confirmed by interviews with the LPN, ADON, and Nurse Consultant, who acknowledged that the evaluations were not completed as required. Additionally, the resident's wound was initially documented as a diabetic foot ulcer but was later reclassified as a pressure ulcer. The change in classification was confirmed by the Nurse Consultant, who noted that the wound was not a diabetic ulcer as previously documented. The resident's care plan highlighted the potential for skin integrity issues due to fragile skin, emphasizing the need for preventive measures and adherence to treatment protocols. Despite these directives, the facility did not conduct the necessary weekly evaluations, leading to a deficiency in care.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide adequate care and services to prevent the development of pressure ulcers for two residents. Resident #10, who has severe cognitive impairment and multiple medical conditions including a stage 4 pressure ulcer, did not receive wound care as per physician orders. The orders specified daily dressing changes for the sacral wound and changes three times a week for the leg amputation wounds. However, observations revealed that the dressings had not been changed since 06/28/2024, indicating a lapse in following the prescribed wound care regimen. Additionally, the last skin audit for this resident was conducted on 05/22/2024, suggesting a lack of regular monitoring. Resident #11, also severely cognitively impaired, had a care plan that required daily wound care for a sacral wound, including cleansing, packing with collagen, and covering with a bordered foam dressing. Despite these orders, the dressing observed on 07/01/2024 was dated 06/28/2024, indicating that the wound care was not performed daily as required. The facility's staff, including the ADON and LPNs, confirmed that the treatment nurse was primarily responsible for wound care, but when unavailable, charge nurses were expected to perform these duties. However, there was confusion and inconsistency among staff regarding access to wound care supplies, which may have contributed to the failure in providing timely care. The facility lacked a wound care policy or guideline, which may have contributed to the deficiencies observed. The Administrator acknowledged that the treatment nurse was responsible for ensuring wound care was performed according to physician orders, but there was no clear accountability or process in place for when the treatment nurse was absent. The last skin audit for Resident #11 was dated 05/28/2024, further indicating a lack of consistent monitoring and documentation of skin conditions.
Failure to Employ Full-Time Director of Nursing
Penalty
Summary
The facility failed to ensure a Director of Nursing (DON) was employed full-time. On July 1, 2024, at 9:15 AM, the Administrator provided a list of key personnel, which did not include a DON. Later that day, at 12:30 PM, the Administrator confirmed that the facility had not had a DON since March 20, 2024, and acknowledged that there was no policy for DON coverage. By 2:30 PM, the Administrator reiterated that the facility should have a full-time DON.
Pest Control Deficiency in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of flies and roaches throughout the building, including the kitchen, dining room, resident rooms, and hallways. Observations by the surveyor on multiple occasions revealed flies on resident food, in common areas, and in the kitchen where food was being prepared. Staff interviews corroborated these findings, with several staff members acknowledging the presence of flies and roaches in various parts of the facility, including the kitchen, dining areas, and resident rooms. The facility's pest control policy states that there should be an ongoing program to keep the building free of insects and rodents. However, despite having a contract with a pest control company, the problem persisted. The Administrator acknowledged awareness of the issue and mentioned that the pest control company had been engaged to address the problem, but the presence of pests continued to be a significant concern, affecting the quality of care and environment for the residents.
Failure to Complete Discharge Summary for Resident
Penalty
Summary
The facility failed to ensure a discharge summary was completed for one of the four sampled residents who were discharged. Resident #3, who had a diagnosis of type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene, was cognitively intact with a BIMS score of 15 and required maximum assistance with activities of daily living. Upon review of Resident #3's medical records on July 1, 2024, it was found that there was no discharge summary present. Interviews conducted on July 2, 2024, revealed that the nurses are responsible for completing the discharge summary upon a resident's discharge, and the facility's administrator confirmed that a discharge summary was not completed for Resident #3. Additionally, it was noted that the facility does not have a policy for discharges.
Failure to Serve Meals Timely to Resident with Malnutrition
Penalty
Summary
The facility failed to serve food in a timely manner to a resident diagnosed with unspecified protein-calorie malnutrition, who was observed sitting at the feed assist table without a meal tray while most other residents had finished their meals. The resident's cognitive skills for daily decision-making were severely impaired, as noted in a recent assessment. During interviews, both the Dietary Manager and the Assistant Director of Nursing (ADON) were unable to explain why the resident had not been served. A Restorative Aide mentioned returning from an appointment, but this did not clarify the delay. The ADON later acknowledged that the resident should not have to wait long periods to be fed, and the Administrator confirmed the absence of a policy on timely meal service.
Failure to Secure Smoking Materials and Provide Adequate Supervision
Penalty
Summary
The facility failed to keep smoking materials secured and provide adequate supervision during all smoke breaks, which could potentially lead to injury. Resident #1, who was cognitively intact with a BIMS score of 14 and had diagnoses of Dementia and COPD, was observed with smoking materials unsecured in their room on multiple occasions. Specifically, a blue package of cigarettes and a white disposable lighter were found on the over-bed table, and two blue packages of cigarettes were found in the bedside table drawer. There were no physician orders or care plan entries addressing the resident's smoking status, and no smoking assessment was located in the resident's health record. Interviews with staff revealed inconsistencies in the supervision of smoke breaks and the storage of smoking materials. LPN #1 and LPN #2 both indicated that residents were not supposed to keep their own smoking supplies, but they had observed residents smoking unsupervised outside of designated smoke break times. CNA #1 confirmed that the responsibility for supervising smoke breaks was not clearly assigned, stating that the activity person was supposed to supervise but that it often fell to whoever had time. The facility's smoking policy, which was reviewed, stated that residents without independent smoking privileges should not have smoking articles except under direct supervision, but this policy was not being followed in practice.
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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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