Premier At The Springs
Inspection history, citations, penalties and survey trends for this long-term care facility in North Little Rock, Arkansas.
- Location
- 3600 Richards Road, North Little Rock, Arkansas 72117
- CMS Provider Number
- 045357
- Inspections on file
- 38
- Latest survey
- August 14, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Premier At The Springs during CMS and state inspections, most recent first.
The facility did not complete a thorough facility assessment to determine appropriate staffing and resource needs for all shifts, nor did it develop a plan for staff recruitment and retention. The assessment team lacked input from direct care staff and residents, and staffing decisions were based on census and minimal requirements rather than resident acuity or needs. Leadership interviews confirmed the facility assessment was not used to guide staffing or operational planning.
Staff failed to follow infection control protocols during wound care for a resident with a surgical wound, including not using barriers, reusing gauze, and improper glove changes. Additionally, two glucometers used for blood sugar checks on multiple residents were not disinfected according to manufacturer guidelines, as an LPN used alcohol pads instead of the required germicidal wipes.
Two residents did not receive necessary assistance with personal hygiene and nail care, despite being unable to perform these activities independently. One resident, with a recent amputation and diabetes, was not assisted with shaving as requested, resulting in significant facial hair growth. Another resident, with paralysis and chronic illness, had long, curled, and discolored toenails that were not addressed despite repeated reports to staff. Facility policies and staff interviews confirmed the expectation for such care, but it was not provided in these cases.
A resident with severe cognitive impairment and on hospice care was the subject of an abuse allegation that was not reported to law enforcement as required by facility policy. Despite internal investigation procedures, there was no evidence of a police report or incident number, and interviews confirmed that the required notification to law enforcement did not occur.
A resident with severe cognitive impairment and limited mobility was observed using a wheelchair that remained visibly dirty over several days, with staff interviews confirming that cleaning was a night shift CNA responsibility. The facility lacked policies or in-service training for wheelchair cleaning, contributing to the failure to maintain necessary equipment in a clean and sanitary state.
The facility did not consistently post all required daily nurse staffing information, specifically omitting the actual hours worked by licensed personnel and, at times, the facility census. Observations confirmed that only staff assignments and numbers by category were displayed, and interviews with the DON and Administrator indicated the postings were intended for staff assignment purposes rather than full regulatory compliance.
A facility failed to accurately complete the MDS for a resident on hospice care. The resident, admitted with Moderate Protein-Calorie Malnutrition, had elected hospice services, but the MDS inaccurately indicated no prognosis of less than six months to live. The error was identified during a review with the MDS Coordinator, who confirmed the mistake.
A resident with respiratory failure and sleep apnea had a physician's order for oxygen therapy, but the care plan did not reflect this need. The MDS indicated the resident received oxygen, yet the care plan was not updated to include this treatment, contrary to facility policy.
The facility failed to ensure proper food storage and sanitation practices, including uncovered food items, improper refrigerator temperatures, expired food, unsanitary kitchen conditions, and inadequate hand hygiene and glove use by staff. These deficiencies had the potential to affect 108 residents.
The facility failed to maintain privacy and dignity for two residents. One resident was exposed during incontinence care without the privacy curtain being pulled, and another was transported uncovered on a shower bed. The CNAs involved acknowledged the lapses, and the DON confirmed the need for privacy measures.
The facility failed to accurately assess the comprehensive assessments for two residents. One resident with bipolar disorder was not correctly documented as PASSAR level II, and another resident with COPD was not accurately coded as a smoker in the MDS. The DON confirmed these inaccuracies, and the facility did not provide the surveyor with an MDS coding policy.
A resident with severe cognitive impairment and a Stage 4 Pressure Ulcer did not receive proper nail care and shaving as per the care plan. Observations and interviews confirmed that the resident's nails were dirty, and his beard was untrimmed, despite facility policies and care plans specifying regular maintenance.
The facility failed to ensure hydration was available at all times for a resident with a diagnosis of constipation. The resident reported not having water all day and often lacking water on weekends. Observations confirmed the absence of water, and a CNA admitted being too busy to pass water that day. The DON confirmed that residents should always have water available.
The facility failed to provide clean oxygen tubing and proper storage for oxygen tubing for two residents on oxygen therapy. Oxygen tubing was observed lying on the floor in one resident's room and not stored in a storage bag for another resident. Staff confirmed that the tubing should be replaced if found on the floor and stored in a bag when not in use.
The facility failed to conduct a side rail assessment for a resident with a Stage 4 Pressure Ulcer, despite the resident being observed with bed rails up on multiple occasions. Staff confirmed the use of side rails without proper assessment, contrary to the facility's 'Bed Safety' policy.
The facility failed to reduce a resident's Sertraline dosage from 125 mg to 100 mg as recommended by the physician. Despite the DON signing the recommendation, the resident continued to receive the higher dosage, and the DON could not explain the oversight.
The facility failed to serve meals according to the planned menu, resulting in residents on mechanical soft diets receiving incorrect portions of pork chili Verde and blackened chicken breast. This affected the nutritional intake of 27 residents on mechanical soft diets and 7 residents on pureed diets.
The facility failed to maintain an effective pest control program, resulting in multiple flies being observed in various areas of the kitchen during meal preparation and serving. Despite regular pest control services, the issue was not addressed, leading to the observed deficiency.
The facility failed to ensure call lights were within reach for several residents, including those with severe cognitive impairments and incontinence issues. Observations showed call lights on the floor, out of reach, despite staff acknowledging the importance of accessibility. This deficiency highlights a lapse in accommodating residents' needs for assistance.
A facility failed to complete a self-administration safety screen for a resident with multiple diagnoses, allowing the resident to have undocumented over-the-counter medications on their nightstand. The medications were observed multiple times over several days, and a self-administration assessment was only completed after the surveyor's observations.
The facility failed to update a resident's care plan to reflect the presence of an indwelling catheter, despite the resident's history of urinary issues and a physician's order for the catheter. The MDS assessment confirmed the catheter's presence, but the care plan was not revised accordingly.
A resident with an indwelling urinary catheter received improper peri care, including incorrect wiping and lack of catheter securing, leading to potential risks of dislodging and trauma. The DON confirmed the correct procedures were not followed, and the facility's policy did not address the specific deficient practice.
Failure to Conduct Comprehensive Facility Assessment for Staffing and Resource Needs
Penalty
Summary
The facility failed to conduct a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. The assessment did not specify staffing requirements for day, evening, night, or weekend shifts based on the needs of the resident population. There was no documented plan for staff recruitment or retention, and the assessment team did not include direct care staff or resident representatives. The assessment relied on census numbers and minimal state requirements rather than a detailed analysis of resident acuity or specific care needs. Additionally, the assessment was not referenced by staff responsible for scheduling or staffing decisions. Interviews with facility leadership revealed a lack of understanding and utilization of the facility assessment in staffing and operational planning. The ADON and DON indicated that staffing decisions were based on corporate direction and minimal state formulas, without reference to the facility's own assessment. The Administrator also did not use the assessment to determine staffing needs, instead relying on general federal requirements. The facility's policy required a detailed review of resident acuity and available resources, but this was not reflected in the actual assessment or in practice.
Infection Control Deficiencies in Wound Care and Glucometer Cleaning
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during wound care and blood glucose monitoring. During wound care for a resident with a surgical wound and wound vacuum on the left foot, the LPN did not follow established infection control protocols. Supplies were placed directly on an un-sanitized over-bed table without a barrier, and no protective barrier was placed under the resident's foot, resulting in purulent drainage contaminating the bed linen. The LPN reused gauze pads to clean the wound, did not change gloves between removing the old dressing and cleaning the wound, and used scissors that had been placed on an un-sanitized surface to cut wound care materials. After the procedure, items such as the skin prep spray and scissors were handled with ungloved hands and placed on the treatment cart without immediate sanitization. Additionally, the facility failed to ensure that glucometers were cleansed according to the manufacturer's guidelines between resident uses. An LPN was observed performing fingerstick blood sugar checks on multiple residents using two glucometers, but did not properly disinfect the devices between uses. Instead of using a registered disinfectant or germicidal wipe as required by the manufacturer, the LPN used alcohol pads to clean the glucometers and only did so after multiple uses. The LPN stated that she had been instructed by management to use alcohol wipes, although the DON was unaware of this change and confirmed that germicidal wipes were the expected method. Facility policy for wound care required establishing a clean field, using barriers to protect linens, performing hand hygiene, changing gloves appropriately, and sanitizing reusable items before returning them to the treatment cart. The policy for glucometer cleaning aligned with the manufacturer's guidelines, which specified the use of a registered disinfectant or bleach solution. These protocols were not followed during the observed incidents, resulting in deficiencies in infection prevention and control.
Failure to Provide Personal Hygiene and Nail Care Assistance
Penalty
Summary
The facility failed to provide necessary personal care and assistance with activities of daily living for two residents who were unable to perform these tasks independently. One resident, admitted with multiple diagnoses including a recent amputation, diabetes, and vascular disease, was documented as requiring moderate assistance with personal hygiene. Despite being cognitively intact and expressing a clear preference to remain clean-shaven, the resident reported only receiving a shave once in the facility's barber shop, for which they had to pay. Over several days of observation, the resident continued to have a significant growth of facial hair, and staff interviews confirmed that CNAs were responsible for assisting with shaving but had not consistently provided this care as requested by the resident. Another resident, admitted with a history of stroke, paralysis, and chronic illnesses, was identified as having a self-care deficit and required assistance with nail care. Although records indicated that the resident's nails were checked regularly, direct observation revealed that the resident's toenails were long, curled, discolored, and jagged. The resident confirmed that the condition of their toenails was bothersome and had been reported to nursing staff multiple times. Interviews with CNAs and nursing staff revealed that there was an established process for nail care, particularly for residents with diabetes or other complicating conditions, but the process was not followed in this case. The resident was not listed for podiatry care, despite the need for professional attention to their toenails. Facility policies required that residents unable to perform activities of daily living independently receive necessary services to maintain grooming and hygiene, and that foot care be provided in accordance with professional standards. Staff interviews confirmed awareness of these policies and the procedures for providing or escalating care needs. However, the failure to provide timely and appropriate assistance with shaving and toenail care for these two residents resulted in unmet personal care needs, as directly observed and reported during the survey.
Failure to Report Abuse Allegation to Law Enforcement
Penalty
Summary
The facility failed to ensure that an abuse allegation involving a resident with severe cognitive impairment was reported to law enforcement as required by facility policy. The resident, who was receiving hospice care and had significant cognitive and communication deficits, was the subject of an internal abuse investigation initiated after an allegation was reported. Upon review of the facility’s investigation records, there was no evidence of a police report or incident number related to the allegation. Interviews with the Administrator and DON confirmed that reporting abuse allegations to law enforcement was part of the facility’s established process. However, the police officer identified by the Administrator as having received the report stated that no such report was made on the specified day, nor was there any record of a report for the entire month in question. The facility’s policy explicitly required immediate notification of law enforcement officials in cases of suspected abuse, neglect, exploitation, or misappropriation.
Failure to Maintain Resident Wheelchair in Clean and Sanitary Condition
Penalty
Summary
The facility failed to ensure that necessary equipment, specifically a resident’s wheelchair, was maintained in a clean and sanitary condition. Over multiple days of observation, the wheelchair assigned to a resident with severe cognitive impairment and limited mobility was found to have visible dirt, white and brown flakes, and crumbs caked on the seat cushion and frame. The resident, who had diagnoses including hypertensive heart disease, vascular dementia, and acute kidney failure, reported that the wheelchair had been dirty for a long time. Staff interviews confirmed that it was the responsibility of night shift CNAs to check and clean wheelchairs, but the resident’s wheelchair remained unclean over several days. Further review revealed that the facility did not have any policies or in-service training related to environmental or wheelchair cleaning. Multiple staff members, including CNAs, LPNs, and the DON, acknowledged that cleaning wheelchairs was part of the night shift CNAs’ duties, but the lack of a formal policy or training contributed to the ongoing issue. The deficiency was identified through direct observation, resident and staff interviews, and review of facility records.
Failure to Post Complete Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the required daily nurse staffing information as mandated. Observations on two consecutive days revealed that while the facility posted staff assignments and the number of licensed staff by category (RN, LPN, CNA), they did not consistently post the facility census or the actual hours worked by licensed personnel. On one day, the census was missing, and on the next, although the census was posted, the actual hours worked were still not displayed. Interviews with the Director of Nursing and the Administrator confirmed that the posted information was intended to show staff assignments and numbers, but did not include all required elements such as actual hours worked.
Inaccurate MDS Assessment for Hospice Resident
Penalty
Summary
The facility failed to ensure the accuracy and completeness of the Minimum Data Set (MDS) for a resident, which is essential for planning and providing necessary care and services. The resident was admitted with a diagnosis of Moderate Protein-Calorie Malnutrition and had elected hospice services. However, the significant change MDS assessment inaccurately marked section J1400 as 'No,' indicating the resident did not have a prognosis of less than six months to live, despite being on hospice care. This error was identified during a review of the MDS with the MDS Coordinator, who acknowledged the mistake and confirmed that section J1400 should have been marked 'Yes' to reflect the resident's hospice status and prognosis.
Failure to Include Oxygen Therapy in Resident's Care Plan
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was developed and implemented for a resident who was admitted with diagnoses of respiratory failure and sleep apnea. The resident had a physician's order for oxygen at two liters per minute as needed, which was documented in the Order Summary Report. However, the care plan dated October 21, 2024, did not reflect that the resident received oxygen as needed, despite the Minimum Data Set (MDS) indicating that the resident was receiving oxygen while in the facility. Interviews with the MDS Coordinator and the Director of Nursing confirmed that they were aware of the physician's order for oxygen and that the MDS indicated the resident received oxygen. Both acknowledged that the care plan should have included this information but did not. The facility's policy on comprehensive, person-centered care plans requires that they include measurable objectives and timeframes and describe the services to be furnished to meet the resident's needs, which was not adhered to in this case.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure proper food storage and sanitation practices in the kitchen and pantry areas. Observations revealed that food items in the refrigerator and freezer were not covered or sealed, including Parmesan cheese, sausage patties, chicken, cobbler crust dough sheets, dinner dough, egg rolls, broccoli, leftover spaghetti, and mixed vegetables. Additionally, the temperature of the upright refrigerator was found to be 51.8 degrees Fahrenheit, which is above the recommended storage temperature. Expired food items, such as vanilla med pass 2.0, were also found in the pantry and medication rooms, and the ice machines in various locations had wet sage-colored residues, indicating inadequate cleaning practices. The kitchen environment was unsanitary, with peeling paint, rust, dirt, and lint accumulation on walls, air vents, and light fixtures. The floor in the storage room had stains, and the baseboard was loose, exposing the cement underneath. Staff members were observed not following proper hand hygiene and glove use protocols, such as not washing hands before handling clean equipment or food items, and contaminating gloves before food preparation. These deficiencies had the potential to affect 108 residents who received food from the kitchen.
Failure to Maintain Resident Privacy and Dignity
Penalty
Summary
The facility failed to maintain privacy and dignity for two residents. Resident #9, who had a history of urinary tract infection, overactive bladder, retention of urine, and acute cystitis, was observed with her blanket pulled back and incontinence brief detached without the privacy curtain being pulled. This exposed the resident to her roommate and anyone entering the room. The CNA involved acknowledged that the privacy curtain should have been pulled before providing care. Resident #13, diagnosed with paraplegia and quadriplegia, was observed being transported on a shower bed down the hall wearing only a hospital gown, without any covering. The CNAs involved admitted they were aware the resident should have been covered but cited reasons such as lack of available blankets and time constraints. The Director of Nursing confirmed that residents should be covered during transport to maintain privacy and dignity. The facility's policy on Resident Rights mandates that all residents be treated with kindness, respect, and dignity, including the right to privacy and confidentiality.
Inaccurate Comprehensive Assessments for Two Residents
Penalty
Summary
The facility failed to accurately assess the comprehensive assessment for two residents, leading to deficiencies in their care plans. Resident #52, diagnosed with bipolar disorder, depression, and anxiety disorder, was documented as having severe cognitive impairment on the Brief Interview of Mental Status (BIMS). However, the Minimum Data Set (MDS) Coordinator was unaware that Resident #52 was considered by the state as PASSAR level II, and this information was not reflected in the electronic records. The Director of Nursing (DON) confirmed that the comprehensive assessment did not accurately reflect Resident #52's PASSAR level II status. Resident #90, diagnosed with depression, old myocardial infarction, and chronic obstructive pulmonary disease (COPD), was documented as a smoker in the Smoking Safety Screen and care plan. However, the Significant Change Minimum Data Set (MDS) did not indicate that Resident #90 was a smoker. The MDS Coordinator confirmed that this information was not coded correctly in the comprehensive assessment. The DON also confirmed the inaccuracy, and the facility did not provide the surveyor with an MDS coding policy or the relevant section of the Resident Assessment Instrument manual used for coding.
Failure to Maintain Resident Hygiene
Penalty
Summary
The facility failed to ensure that Resident #104 received proper care for activities of daily living, specifically in maintaining clean nails and providing regular shaves. Resident #104, who has a diagnosis of a Stage 4 Pressure Ulcer in the sacral region and severe cognitive impairment, required substantial assistance with bathing. Despite this, observations on multiple occasions revealed that the resident's nails had a black substance underneath, and his beard was approximately 2 inches long. The resident confirmed that he had not been shaved since his admission and that staff did not clean his nails. Facility policies dated 05/08/2024 for shaving and nail care were reviewed, indicating the importance of cleanliness and infection prevention. However, interviews with staff, including a Certified Nurse Aid (CNA) and the Director of Nursing (DON), confirmed that the resident's nails and beard were not being maintained as per the care plan, which specified nail cleaning and shaving on Tuesdays, Thursdays, and Saturdays. The CNA acknowledged the need for nail cleaning and shaving, and the DON confirmed the expected frequency of these tasks, highlighting a clear lapse in the execution of the resident's care plan.
Failure to Ensure Hydration Availability
Penalty
Summary
The facility failed to ensure hydration was available at all times for Resident #69, who had a diagnosis of constipation and was cognitively intact with a BIMS score of 15. On 5/05/24 at 11:58 AM, Resident #69 informed the surveyor that they had not had any water all day and often lacked water on weekends. At 12:30 PM and 1:40 PM on the same day, it was observed that Resident #69 still did not have water available. Certified Nurse Aide #11 admitted that she had not had a chance to pass water that day due to being busy, although she usually did so twice a day. The Director of Nursing confirmed that residents should have water available at all times.
Failure to Provide Clean and Properly Stored Oxygen Tubing
Penalty
Summary
The facility failed to provide clean oxygen tubing and proper storage for oxygen tubing for two residents on oxygen therapy. On multiple occasions, a surveyor observed oxygen tubing lying on the floor in Resident #32's room. When questioned, a CNA stated that the appropriate action would be to notify the nurse, and the DON confirmed that the tubing should be immediately replaced if found on the floor. Additionally, the facility's oxygen administration policy was provided by the DON. For Resident #97, who had a diagnosis of Moderate Persistent Asthma and a severe cognitive impairment as indicated by a BIMs score of 00, the surveyor observed the oxygen tubing not being stored in a storage bag when not in use. The tubing was found on top of the oxygen machine on multiple occasions. Both RN #1 and the DON confirmed that the tubing should be stored in a storage bag when not in use. These observations indicate a failure to adhere to proper respiratory care protocols for residents on oxygen therapy.
Failure to Conduct Side Rail Assessment for Resident
Penalty
Summary
The facility failed to ensure bed rails were not used for Resident #104 without a side rail assessment to prevent potential accidents. Resident #104, who had a diagnosis of Pressure Ulcer Sacral Region Stage 4, was observed with bed rails up on multiple occasions. The Medicare-5 Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/08/24 did not indicate that Resident #104 used side rails, and a side rail assessment dated [DATE] also indicated no use of bed rails. Despite this, Resident #104 was observed with bed rails up on 5/05/24, 5/06/24, and 5/07/24. Certified Nurse Aide (CNA) #11 confirmed that Resident #104 had been using side rails since admission. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed the use of side rails without a proper assessment. The facility's policy titled 'Bed Safety' requires an interdisciplinary assessment, consultation with the attending physician, and input from the resident or legal representative if side rails are used.
Failure to Implement Gradual Dose Reduction for Antidepressant Medication
Penalty
Summary
The facility failed to implement a gradual dose reduction for a resident diagnosed with Major Depressive Disorder. Despite a physician's recommendation to reduce the resident's Sertraline dosage from 125 milligrams to 100 milligrams daily, the reduction was not carried out. The Director of Nursing (DON) signed the recommendation, but the resident continued to receive the original dosage of 125 milligrams as documented in the Medication Administration Records for April and May 2024. Both the Licensed Practical Nurse (LPN) and the DON confirmed that the resident was still receiving the higher dosage, and the DON was unable to explain why the physician's order was not implemented. The deficiency was identified during a review of the resident's records and interviews with the facility staff. The resident, who scored 13 on the Brief Interview for Mental Status (BIMs), indicating cognitive intactness, had been on Sertraline since June 2023. The failure to reduce the dosage as recommended by the physician highlights a lapse in the facility's medication management and order implementation processes. The DON acknowledged the oversight but did not provide a reason for the failure to update the medication order in the system.
Failure to Serve Meals According to Planned Menu
Penalty
Summary
The facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents. Specifically, for two observed meals, the facility did not provide the correct portions of pork chili Verde and blackened chicken breast to residents on mechanical soft diets. On 05/07/24, the menu indicated that residents on mechanical soft diets should receive 3/4 cup of pork chili Verde. However, the dietary employee used a 6-ounce spoon to prepare the servings, and only 7 servings were prepared instead of the required amount. Additionally, the dietary supervisor confirmed that they ran out of mechanical soft meat during the lunch meal, and the dietary employee could not recall the exact portion sizes served to each resident. On 05/08/24, the menu indicated that residents on mechanical soft diets should receive 4 ounces of blackened chicken breast. However, the dietary employee used a 2-ounce spoon to serve the chicken, providing only one serving to each resident. These actions resulted in the residents not receiving the appropriate portions as per the planned menu, potentially affecting the nutritional intake of 27 residents on mechanical soft diets and 7 residents on pureed diets.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to ensure an effective pest control program was maintained to keep the facility free of pests. During an observation on 05/07/24 at 10:50 AM, multiple flies were seen in various areas of the kitchen during meal preparation and serving. Specifically, flies were observed on a cart by the food preparation sink, on the wall near the dishwashing machine, by the plate warmer, and flying around the food preparation area. Further observations at 11:26 AM and 11:53 AM revealed additional flies on clean dish racks, a box of iodized salt, a window by the food preparation counter, a menu, a microwave, and a refrigerator. The Dietary Supervisor confirmed the presence of flies and noted that the issue had recently started due to warmer weather and flies being outside the back door. The facility's pest control records indicated that monthly pest control services were performed, but flies were not reported in the documentation. The records from 02/22/24, 02/26/24, 03/21/24, and 04/22/24 showed that the pest control service focused on roach activity and exterior bait stations, with no mention of flies. Despite the regular pest control services, the facility did not effectively address the fly infestation in the kitchen, leading to the observed deficiency.
Failure to Ensure Call Lights Within Reach
Penalty
Summary
The facility failed to ensure that call lights were within reach for four out of five residents reviewed for call light accessibility. Observations by the surveyor revealed that multiple residents, including those with severe cognitive impairments and incontinence issues, did not have their call lights within reach. For instance, one resident with a history of repeated falls and severe cognitive impairment was observed multiple times with the call light on the floor, out of reach, despite being awake and in bed. Another resident, who was cognitively intact, expressed frustration over the call light being on the floor and not being answered promptly. Interviews with CNAs and the Director of Nursing confirmed the importance of ensuring call lights are within reach to prevent risks such as falls, dehydration, and skin breakdown. Despite this understanding, the surveyor's observations indicated a consistent failure to adhere to this practice, as evidenced by the repeated instances of call lights being inaccessible to residents. This deficiency highlights a significant lapse in the facility's responsibility to accommodate the needs and preferences of its residents, particularly in ensuring their ability to call for assistance when needed.
Failure to Complete Self-Administration Safety Screen
Penalty
Summary
The facility failed to complete a self-administration safety screen for a resident (Resident #27) to ensure that the resident could safely administer medication. The resident had several diagnoses, including hypertension, chronic kidney disease stage 4, old myocardial infarction, chronic obstructive pulmonary disease, atrial fibrillation, and benign prostatic hyperplasia with lower urinary tract symptoms. Despite these conditions, the resident had multiple over-the-counter medications on their nightstand, including allergy relief medication, lidocaine gel, and antifungal powder, which were not documented in the physician's orders. The resident also had an antacid and cold and flu syrup in the nightstand, which were confirmed by an LPN. The resident's care plan indicated that medications should be administered in accordance with the physician's orders and the resident's ability to safely take them, but no self-administration assessment had been completed until after the surveyor's observations. The surveyor observed the medications on the resident's nightstand multiple times over several days, indicating that the medications were consistently accessible to the resident without proper assessment. The Director of Nursing confirmed that a self-administration assessment was only completed after the surveyor's observations. The facility's policy on self-administration of medications states that residents have the right to self-administer medications if the interdisciplinary team has determined it is clinically appropriate and safe, which was not adhered to in this case.
Failure to Update Care Plan for Indwelling Catheter
Penalty
Summary
The facility failed to ensure that the care plan for a resident was revised to reflect the presence of an indwelling catheter. The resident had a history of urinary tract infection, overactive bladder, retention of urine, and acute cystitis. The physician's order indicated the use of a 16 French indwelling urinary catheter with a 10 cubic centimeter balloon. The Minimum Data Set (MDS) assessment confirmed the resident had an indwelling catheter and was always incontinent of bowel. Despite this, the care plan, last revised on 4/30/24, did not accurately reflect the presence of the indwelling catheter, although it included interventions related to catheter care initiated on 04/04/2024. On 05/08/24, the Minimum Data Set Coordinator and the Director of Nursing confirmed that the care plan was not updated to reflect the resident's current condition. The facility's policy on comprehensive person-centered care planning states that assessments are ongoing and care plans should be revised as the resident's condition changes. This failure to update the care plan was identified during observations, interviews, and record reviews conducted by the surveyors.
Improper Incontinence and Catheter Care
Penalty
Summary
The facility failed to ensure proper incontinence care for a resident with an indwelling urinary catheter, leading to potential risks of dislodging and trauma. Resident #9, who had a history of urinary tract infections and other related conditions, was observed receiving improper peri care from CNA #8. The CNA wiped stool downward, which is incorrect, and did not ensure the catheter was positioned to prevent pulling and strain. Additionally, there was no stat lock in place to secure the catheter, increasing the risk of dislodging and trauma. The Director of Nursing confirmed that peri care should be performed correctly and that the catheter should be disconnected from the bed to prevent pulling. The facility's policy on urinary incontinence did not address the specific deficient practice observed. This failure in care had the potential to affect other residents with indwelling catheters in the same hall.
Latest citations in Arkansas
Two residents with moderate cognitive impairment and independent mobility were repeatedly seeking each other’s attention and were found by a CNA on the floor with their pants down, appearing to be engaged in consensual sexual activity. Staff separated them and returned them to secure units, and an LPN reported there was no plan for a consensual sexual relationship or private time, despite awareness of prior similar behavior. Both residents described themselves as being in a loving relationship, but the facility completed no assessments related to sexual activity, made no related care plan revisions, and obtained no orders for contraception, STD testing, or specialty consults. Conversations held by leadership with the residents about privacy and protection were not documented, and there was no facility policy addressing resident sexual relations, despite a general resident rights policy referencing self-determination and support in exercising rights.
The facility failed to develop and implement comprehensive care plans addressing sexual health and a consensual sexual relationship for two cognitively impaired, independently mobile residents with psychiatric and neurological diagnoses. Both residents were known to seek each other’s attention and had a prior relationship, yet their care plans only directed staff to separate and redirect them, without any individualized interventions for sexual health, privacy, or safe sex. A CNA later found the two residents on the floor with their pants down, appearing to engage in consensual sexual activity, and they were separated by staff. Subsequent staff interviews confirmed there was no documented assessment, no care plan revisions for sexual health or the relationship, no safe sex education, no established access to contraception, and no facility policy on resident sexual relations.
A resident with hemiplegia, hemiparesis, a below-knee amputation, moderate cognitive impairment, and wheelchair dependence was transported in a facility van by a CNA who had previously been in-serviced and skills-checked on van safety. During the trip, the CNA secured only three of the four required wheelchair floor locks, and a hold-down device had been removed from the van and not replaced. As the CNA drove over a road irregularity and braked, the incompletely secured wheelchair tilted backward, causing the resident to fall onto the van floor and report head pain with a nodule at the base of the skull. Facility policy required an environment free from accident hazards and staff competency in preventing avoidable accidents, but the missing tie-down and failure to fully secure the wheelchair led to this transport-related fall.
Surveyors found that the facility failed to follow physician orders for PICC line dressing changes, wound care, and catheter care for two residents. One resident with osteomyelitis, pressure ulcers, and an indwelling catheter had multiple missing entries on the TAR for ordered PICC line dressing changes, daily pressure ulcer treatments to the heel and coccyx, and catheter care every shift, with the DON confirming that blank TAR blocks indicated treatments were not completed. Another resident with a PICC line for antibiotic therapy had an order for weekly dressing changes, but the dressing was not changed as scheduled, the PICC site was left uncovered for several minutes during medication administration, and an LPN admitted initialing the TAR to indicate a dressing change that she had not performed, while the TN and APN confirmed the order required adherence to the weekly schedule.
A resident with MRSA colonization and a PICC line for IV antibiotics experienced multiple breaches in infection control by nursing staff. An LPN repeatedly double-gloved, handled room surfaces, trash can lids, and the medication cart, then donned new gloves without performing hand hygiene before preparing and administering oral and IV medications. During PICC access, the LPN wiped the access port for only a few seconds, allowed IV tubing to touch bedding, let the access port fall onto the resident’s arm, and then re-accessed the line without hand hygiene or glove changes. At another time, the PICC site was left uncovered while a treatment nurse prepared for a dressing change, and the LPN entered without prior hand hygiene, disconnected IV tubing, and flushed the line after only a brief alcohol wipe. Staff interviews showed uncertainty and inconsistency regarding required scrub times, glove use, and dressing change schedules, which conflicted with facility policies and stated expectations for aseptic PICC care and hand hygiene.
A resident with dementia, anxiety, depression, and on hospice had a Durable Power of Attorney, Living Will, and signed DNR order all specifying no CPR, and the face sheet reflected no CPR; however, physician orders, a MD progress note, and the MAR repeatedly listed the resident as full code from admission onward. Nursing staff and leadership (including a RN, LPN, ADON, DON, and the Administrator) acknowledged that while the advance directives and resuscitate/DNR form showed DNR status, the active orders and MAR still indicated full code, even though staff commonly rely on these documents to determine code status, contrary to facility policy requiring alignment of the care plan and physician orders with the resident’s documented treatment preferences.
A resident with depression, insomnia, and non-Alzheimer’s dementia experienced a documented decline from moderate to severe cognitive impairment on successive MDS assessments, but the care plan was not revised and continued to include an active "Sexual Expression" problem allowing engagement in sexual behavior with other consenting residents. This care plan had been initiated after an incident where two residents were found in bed together partially undressed and engaging in intimate behavior. The resident’s responsible party stated the resident was not capable of consenting to sexual activity, an LPN reported the resident could not express needs or make decisions about sexual relationships, and another LPN stated the care plan no longer reflected the resident’s needs due to steady decline. The Social Services Director had previously completed sexual consent questionnaires only at the time of the incident, and the Medical Director indicated that a sexual activity care plan was not appropriate for a resident with a very low BIMS score, while the Administrator acknowledged care plans were expected to be updated when MDS changes occurred.
A resident with traumatic brain injury, stroke history, and altered mental status was placed on a secured unit for elopement risk but had only general care plan interventions that were not updated when new wandering, exit‑seeking, and aggressive behaviors emerged. Over time, staff documented that the resident walked the halls at night, entered other residents’ rooms, voiced not living there, stated plans to leave through a window, followed staff through locked doors, and sought ways to get out after a home visit. Despite an elopement assessment and multiple behavior notes, no individualized elopement‑prevention interventions were added to the care plan. Eventually, during a night shift when a CNA reported dozing off and not re‑checking the room, the resident broke a bedroom window with furniture, left the building, and was later found off‑site by police after nearly being hit by a car, confirming that the care plan had not been effectively revised or implemented to address the resident’s exit‑seeking behaviors.
A resident with traumatic brain injury, altered mental status, and a history of wandering was housed on a locked unit with a care plan identifying elopement risk but focused mainly on therapeutic activities and medication monitoring. After returning from a home visit, the resident exhibited escalating behaviors over several days, including being up all night walking halls, entering other residents’ rooms, standing at locked exits, following staff out locked doors, voicing a desire to leave, and stating a plan to escape through a window. On the night of the incident, camera footage showed the resident moving between the room, day room, and bathroom until entering the room and not re-emerging, while the CNA on duty did not perform checks, reported that staff did not usually re-check the resident once in the room, and admitted to dozing off. The resident broke the bedroom window with furniture, left the building unnoticed, and was later found by police nearly two miles away after a citizen reported almost hitting the resident with a car, demonstrating that the facility failed to provide adequate supervision and monitoring during a period of increased exit-seeking.
Two residents with significant cognitive and neuromuscular/orthopedic conditions experienced falls when staff did not follow care-planned assistance and supervision requirements. One resident, care-planned for two-person assist with bed mobility, transfers, and personal hygiene, was found on the floor after a CNA attempted incontinent care alone. Another resident, care-planned for staff assistance with dressing and two-person assist for transfers with a slide board, was left seated at the edge of the bed and told to dress themself; the resident fell while unattended and was later found on the floor wearing a C-collar. CNAs reported relying on the electronic care plan/Kardex for instructions, but one CNA described unclear and brief initial training on accessing the system, while leadership stated CNAs were expected to verify care needs in the electronic care plan before each care episode.
Failure to Support and Assess Consensual Sexual Relationship Between Residents
Penalty
Summary
The deficiency involves the facility’s failure to support residents’ rights to engage in a consensual sexual relationship between two cognitively impaired residents. Both residents had documented moderate cognitive impairment on their MDS assessments (BIMS scores of 11 and 12) and were independent with mobility. Their care plans identified "inappropriate seeking of other individual's attention" with interventions limited to separating and redirecting them. There was no documented assessment of their capacity for sexual decision-making or sexual activity either before or after an incident in which they were found with their pants down on the floor together. On the date of the incident, a CNA discovered the two residents in a room with their pants down, appearing to be having sex, and reported that it looked like they were consenting and that she had been told they had a history together. The CNA notified an LPN, and the residents were separated and returned to their secure units. The LPN confirmed there was no plan in place to allow a consensual sexual relationship or to provide private time for the residents, despite being aware that similar behavior had occurred previously. Interviews with the residents indicated that they viewed themselves as being in a relationship, that they loved each other, and that they did not intend harm. Record review showed no orders for birth control, sexually transmitted disease testing, or referrals to specialized clinics or physicians for either resident. There was no documentation in progress notes of education or conversations with staff regarding the incident, and no assessments related to sexual activity were completed before or after the event. The MDS nurse and Administrator acknowledged speaking with the residents about the incident and the possibility of providing privacy and protection, but the MDS nurse stated that none of these discussions or interventions were documented and nothing was added to the care plans. The Administrator also stated the facility did not have a policy on resident sexual relations, despite a resident rights policy referencing residents’ rights to self-determination and to be supported in exercising their rights.
Failure to Care Plan for Residents’ Sexual Health and Consensual Relationship
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, measurable care plans addressing sexual health and consensual sexual relationships for two cognitively impaired residents. Resident #3, admitted with traumatic brain injury, bipolar disorder, mood disorder, and an unspecified mental disorder, had a BIMS score of 11 indicating moderate cognitive impairment and was independent with mobility. Resident #4, admitted with schizophrenia, schizoaffective disorder bipolar type, dementia, and psychosis, had a BIMS score of 12, also indicating moderate cognitive impairment, and was independent with mobility. Both residents’ care plans, updated on 03/11/2026, identified “inappropriate seeking of other individuals’ attention,” but the only interventions listed were to separate and redirect, with no individualized care plan addressing their sexual health, their ongoing relationship, or parameters for consensual sexual activity. On 03/11/2026, a CNA discovered Resident #3 and Resident #4 on the floor with their pants down, appearing to be engaged in consensual sexual activity. The CNA notified an LPN, and staff separated the residents and returned them to their secure units. Staff interviews revealed that there was no existing plan for a consensual sexual relationship, no plan for private time, and no documented assessment or care plan interventions related to sexual health, safe sex education, or contraception for these residents, despite knowledge of a prior relationship and the residents’ expressed desire and intent to engage in sexual activity. The MDS nurse and the Administrator acknowledged that no care plan revisions were made to address sexual health or the relationship, no documentation of related discussions or interventions was completed, and the facility had no policy on resident sexual relations and no established interventions for birth control.
Failure to Properly Secure Wheelchair During Van Transport Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s wheelchair was fully and properly secured with all required safety straps before transport in the facility van, resulting in the resident falling backwards in the van. The resident had physician orders for LTC admission and diagnoses including hemiplegia and hemiparesis affecting the right dominant side, as well as an acquired absence of the left leg below the knee. The resident’s MDS showed moderate cognitive impairment, functional limitations in lower extremity range of motion bilaterally, and use of a wheelchair for mobility. The care plan documented a self-care performance deficit requiring limited assistance by one staff for transfers and noted an actual fall earlier in the month, with an intervention for staff education on proper van transport. On the date of the incident, the resident was being transported in the facility van by a CNA who served as the van driver. According to the facility’s reportable and the CNA’s written witness statement, the CNA applied two back floor locks and one front floor lock to secure the wheelchair but did not secure all four required locks. During the drive, as the CNA approached a dip or hump in the road and applied the brakes, the resident’s wheelchair tilted backwards. The resident stated they were falling, and when the CNA stopped the van, she found the resident lying flat on their back on the van floor with the wheelchair also on the floor. Nursing documentation indicated the resident reported pain at the base of the skull, had a nodule on the back of the head, and declined transfer to the emergency room. Interviews and document reviews showed that the CNA had previously received in-service training and skills checkoffs on how to properly secure residents in the van and had signed best-practice forms stating that wheelchairs would be securely attached to the van body and kept centered during transport. The Administrator reported that the CNA admitted she did not use the correct number of straps to secure the wheelchair and that a hold-down device (tie-down/safety strap) had been removed from the smaller van to be used in a larger van and was not replaced. The Maintenance staff confirmed that a hold-down device for the back of the wheelchair was missing from the van used for the transport and that tie-downs were interchangeable between vans. Subsequent observation with other CNAs demonstrated that when all four locks and the seat belt were properly engaged, the wheelchair did not move, but loosening the front locks allowed the wheelchair to move, illustrating how incomplete securement could permit wheelchair movement during transport. The facility’s Safety and Supervision of Residents policy stated that the environment should be made as free from accident hazards as possible and that employees should be trained and demonstrate competency in identifying and preventing accident hazards. Despite this policy and prior in-services, the resident’s wheelchair was not fully secured with all required straps at the time of transport, and a necessary hold-down device was missing from the van, directly contributing to the resident’s fall inside the vehicle.
Failure to Follow Physician Orders for PICC Line, Wound, and Catheter Care
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for PICC line dressing changes, wound care, and indwelling catheter care for two residents. One resident was admitted with osteomyelitis of the vertebra, sacral and sacrococcygeal region, type 2 diabetes mellitus, and a pressure ulcer, and had a BIMS score indicating moderate cognitive impairment. Physician orders included a PICC line dressing change every three days, daily dressing changes to an unstageable right heel pressure ulcer, daily cleansing and dressing of an unstageable coccyx pressure ulcer, and catheter care every shift and PRN with soap and water or wipes for wound healing. Review of the Treatment Administration Record (TAR) for June showed multiple dates where there were no initials or check marks to indicate that the PICC line dressing changes, right heel dressing changes, coccyx pressure ulcer treatments, and catheter care had been completed as ordered. The TAR for this resident showed no documentation of PICC line dressing changes on several specified dates, despite an active order for changes every three days. Similarly, the TAR lacked initials or check marks for the ordered daily dressing changes to the right heel pressure ulcer on multiple dates. For the coccyx pressure ulcer, there were two separate orders—one to cleanse and apply wet-to-dry dressings with a specific brand dressing and island dressing every day shift, and a later order to cleanse and apply wet-to-dry dressings with a specific brand dressing and foam dressing every day shift. On several dates, the TAR contained open blocks with no initials or check marks, indicating that these treatments were not completed. Additionally, the TAR showed that catheter care ordered every shift and PRN was not documented as completed on multiple day shifts over a series of days. The DON confirmed that open blocks on the TAR indicated treatments were not completed. For the second resident, who was admitted with infection and inflammatory reaction due to an internal left hip prosthesis, MRSA, and pain related to orthopedic prosthetic devices, there was an order for a PICC line dressing change to the left upper arm every Wednesday on the day shift. The March TAR reflected this order and showed documented dressing changes on two Wednesdays, with check marks and initials indicating the treatment had been administered. During a medication pass observation, an LPN examined the PICC line dressing and was unsure of the last dressing change date, noting that the handwritten date on the dressing was unclear and that PICC line dressings could only be changed by an RN. Later observation showed the treatment nurse at the bedside with the PICC line site uncovered after the dressing had been removed, while the LPN administered oral medications and hung an antibiotic through the PICC line, leaving the site uncovered for several minutes. The treatment nurse stated the dressing change had been due the previous day but was not completed because the dressing was not available, and also stated she signed the TAR after completing the dressing change. Further interviews revealed documentation discrepancies for this second resident. The DON’s nursing incident/accident note documented that the PICC line dressing change was not completed on the scheduled day and was instead changed the following day. The LPN later acknowledged that the initials on the TAR for the scheduled dressing change date were hers, and admitted she had not changed the dressing but had only looked at it after being told by the treatment nurse that the dressing was within a seven-day time frame. She stated she placed her initials in the TAR block to indicate she had looked at the dressing, even though the TAR coding indicated that initials in the block meant the treatment was given. The treatment nurse reported changing the dressing on one earlier date and, when changing it later, observed a written date on the removed dressing that did not match any documented TAR entry and could not identify whose initials were on that dressing. The treatment nurse and APN both confirmed that the physician’s order required the dressing to be changed every Wednesday and that, even if changed on another day, it still needed to be changed on Wednesday per the order. The DON confirmed that staff initials in a TAR block indicated the treatment was given, an X indicated the treatment was not ordered for that day, and an open block indicated the treatment was not completed.
Improper Hand Hygiene and PICC Line Management During MRSA-Positive Resident Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper infection prevention and control practices during the care of a resident with a PICC line and MRSA colonization. The resident was admitted with diagnoses including infection and inflammatory reaction due to an internal left hip prosthesis, MRSA, and pain related to orthopedic prosthetic devices. The resident had a PICC line in the left arm for IV antibiotic therapy to treat the hip infection, and the care plan included contact isolation, use of gowns and gloves during physical contact, handwashing before leaving the room, and standard precautions for infection control. Orders and the TAR showed that PICC line dressings were to be changed weekly, and the MAR showed daily IV antibiotic administration. Surveyor observations on one morning showed that an LPN performed hand hygiene and donned two pairs of gloves along with other PPE before entering the resident’s room to obtain blood pressure and administer medications. The LPN entered the room multiple times, repeatedly double-gloving, and handled the blood pressure cuff, trash can lid, medication cart, and medication cards without performing hand hygiene between glove removal and donning new gloves. At one point, the LPN removed gloves, closed the trashcan lid with a gloved hand, then removed gloves and immediately donned a clean pair without hand hygiene before preparing and administering the resident’s oral medications. Later, when preparing to administer IV antibiotic through the PICC line, the LPN again donned PPE, placed supplies on paper towels on the overbed table, removed the cap from the PICC access port, and wiped the port with an alcohol pad for less than three seconds before flushing with normal saline. During this process, IV tubing touched the resident’s bedding, the access port fell back onto the resident’s arm, and the LPN discarded the contaminated tubing, obtained new tubing, and again wiped the access port for less than three seconds before attaching the tubing and starting the IV medication, without performing hand hygiene or changing gloves during the sequence. A subsequent observation the same day showed the treatment nurse at the bedside with the resident’s PICC line dressing removed, leaving the site uncovered while the resident looked at the open site and was not wearing a mask. The LPN entered without performing hand hygiene before donning PPE, administered oral medication, disconnected the IV tubing from the PICC line, wiped the access port for three seconds, and flushed with normal saline. The treatment nurse stated responsibility for PICC dressing changes and believed the last dressing change had occurred the prior week, but also reported that the dressing removed that day was marked with a date indicating it was due for change the previous day and that the dressing had not been changed because supplies had to be ordered. Facility records showed that the TAR had been signed for a PICC dressing change on a scheduled day, while later nursing documentation described that a dressing change ordered for a specific day had not been performed as ordered. Facility policies and CDC-based documents required hand hygiene before and after glove use, hand hygiene after glove removal, and disinfection of needleless access devices for at least 15 seconds, and the DON stated that the PICC port should be cleaned for 15 seconds and that the dressing should be in place before starting medication, which contrasted with the observed practices. Interviews with the LPN revealed that double gloving was used so gloves would not have to be changed as often, and the LPN acknowledged that hand hygiene should have been performed after removing gloves and before donning new ones. The LPN initially could not state the required length of time for scrubbing the PICC access port and later stated it should have been cleaned for at least 15 seconds, which differed from the observed practice of wiping for less than three seconds. The treatment nurse described limited availability of PICC dressing kits and that no specific person was responsible for ordering them, and reported having changed the resident’s PICC dressing two to three times since admission. The APN and DON both stated expectations that PICC sites and access ports be kept sterile or clean during medication administration and flushing, that staff use only one set of gloves at a time with handwashing between glove changes, and that the PICC port be cleaned for 15 seconds with alcohol swabs even when medicated caps are used. These expectations and policies contrasted with the observed failures in hand hygiene, glove use, PICC port disinfection, and maintaining an intact dressing prior to accessing the PICC line.
Inconsistent Documentation of DNR Status in Medical Record
Penalty
Summary
The facility failed to ensure that one resident’s medical record accurately and consistently reflected the resident’s advance directive specifying no Cardiopulmonary Resuscitation (CPR). The resident had non-Alzheimer’s dementia, anxiety, depression, moderate impairment in decision-making, and was receiving hospice services. Documentation in the record included a Durable Power of Attorney for Health Care, a Living Will Declaration, and a Resuscitate/Do Not Resuscitate order, all indicating that CPR and chest compressions were to be withheld and that the resident was a Do Not Resuscitate (DNR). The resident’s face sheet also indicated an advance directive for no CPR. Despite these documents, multiple parts of the electronic health record and physician documentation identified the resident as a full code. Physician’s orders from admission onward, including after the resident was admitted to hospice, contained orders indicating full code status. A MD progress note also documented the resident as a full code, and the Medication Administration Record (MAR) for the reviewed period listed the resident as full code. These entries conflicted with the existing DNR orders and advance directive documents in the record. Interviews with nursing staff and leadership confirmed awareness of the discrepancy between the resident’s documented advance directives and the active physician orders and MAR entries. A RN, an LPN, the ADON, the DON, and the Administrator each acknowledged that the resident’s advance directives and resuscitate/do not resuscitate order indicated DNR status, while the current physician orders and MAR showed full code. Staff stated that code status is typically verified using the medical record, MAR, and face sheet, and they recognized that the inconsistency meant staff could rely on incorrect information about whether to initiate CPR. Facility policy required that advanced directives be respected, that the plan of care be consistent with documented treatment preferences, and that the physician be notified so appropriate orders could be documented in the medical record and care plan, which did not occur in this case.
Failure to Revise Sexual Expression Care Plan After Cognitive Decline
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive care plan after a significant decline in cognitive status and changes documented on the quarterly MDS. One resident with active diagnoses of depression, insomnia, and non-Alzheimer’s dementia had a BIMS score of 09 on the 07/30/2025 quarterly MDS, indicating moderate cognitive impairment, which later declined to a BIMS score of 03 on the 01/05/2026 quarterly MDS, indicating severe cognitive impairment. Despite this documented decline, the resident’s care plan continued to include an active problem of “Sexual Expression,” initiated on 08/15/2025 after an incident in which the resident was found in another resident’s bed with both residents partially undressed and engaging in intimate behavior. The care plan goal was to allow the resident to engage in sexual behavior with other consenting residents, with interventions focused on ensuring appropriate consent, providing privacy, and observing for changes in mood or cognition. Interviews and record reviews showed that the care plan was not updated to reflect the resident’s current cognitive status or capacity for consent. The resident’s responsible party stated that the resident was not capable of consenting to sexual relationships or activity and had not been capable for a long time, and identified themselves as the decision maker. An LPN familiar with the resident reported that the resident could not express needs or wants and did not believe the resident was ever capable of making decisions about a sexual relationship, despite what was documented on the care plan. Another LPN stated that the current care plan was not accurate due to the resident’s steady decline. The Social Services Director reported completing sexual consent questionnaires for both involved residents at the time of the original incident and determining they could consent, but acknowledged the form was not set to repeat on subsequent assessments. The Medical Director stated that a care plan for sexual activity for a resident with a BIMS score of 03 was not appropriate because sexual knowledge would be low, and the Administrator confirmed that care plans were expected to be updated quickly when the MDS reflected a change, underscoring that this did not occur for this resident’s sexual expression care plan.
Failure to Update Care Plan for New Exit-Seeking Behaviors Leading to Elopement
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement an effective, updated comprehensive care plan with individualized interventions in response to new onset wandering, exit‑seeking, and elopement‑related behaviors for a resident on a secured unit. The resident had a history of traumatic brain injury, cerebral infarction (stroke), altered mental status, and was admitted to the secured unit due to traumatic brain injury and elopement risk. A quarterly MDS showed the resident was cognitively intact with a BIMS score of 12 and independent with ambulation, but a later BIMS showed a score of 2, indicating moderately impaired cognition. Despite these changes and the resident’s known elopement risk, the care plan initiated months earlier contained only general interventions such as therapeutic activities and medication monitoring, and no additional or revised interventions were added after 08/25/2025 to address later‑emerging behaviors or elopement attempts. On 01/13/2026, multiple progress notes documented significant behavioral changes and explicit exit‑seeking behavior. Early that morning, staff recorded that the resident was up all night walking the halls, refusing to go to bed, entering other residents’ rooms, and voicing that they did not live in the facility. The resident stated an intent to get out of the window. Later that day, another note documented that the resident had been seeking elopement since returning from a home visit, admitted a desire to leave, had been looking for ways to get out, and followed staff out locked doors, showing force when staff tried to return the resident to the unit. A further note that evening described the resident talking loudly, being aggressive toward staff, and again stating a desire to get out of the facility. Although an elopement assessment was completed at that time, there were no new care plan interventions put in place to guide staff in preventing exit‑seeking or managing the aggressive behaviors. In the weeks that followed, staff interviews and documentation showed that the resident continued to exhibit wandering and exit‑seeking behaviors without corresponding care plan revisions. Staff reported that after a family home visit, the resident began trying to leave the unit, walked door to door asking how to get out, watched staff to see if they were paying attention, and talked about leaving. On the night of the elopement, camera footage showed the resident repeatedly moving between the room, day room, and bathroom before entering the room and not re‑emerging. A CNA on duty stated that the resident had been going in and out of the room earlier in the shift, then went back to the room and was not checked on again; the CNA also reported dozing off during the shift and not hearing the window break. In the early morning hours, staff discovered the resident’s window busted and the resident missing, and a progress note documented that the resident had eloped by throwing an end table through the window. A police report and interviews confirmed that the resident was found off‑site after nearly being struck by a vehicle, having left the facility to find family. Throughout this period, the facility did not update the resident’s care plan with individualized, effective interventions to address the clearly documented new onset wandering, exit‑seeking, and elopement behaviors.
Removal Plan
- Revise Resident #1's care plan to include individualized elopement prevention interventions updated to include all interventions per the Plan of Removal.
- Complete new elopement risk assessments for residents residing on the secured unit.
- For any resident scoring moderate or high risk, review care plans to ensure individualized elopement interventions are present.
- Complete environment exit safety checks.
- Revise and update all secured unit residents' care plans based on the Plan of Removal.
- Provide in-service education to nursing and direct care staff on the elopement policy and missing resident procedures.
- Provide in-service education to nursing and direct care staff on the definition and examples of elopement and exit-seeking behaviors, early warning signs requiring interventions, and requirements to notify the nurse, administrator, or DON of new or increased behaviors.
- Provide in-service education to nurse management responsible for updating care plans on mandatory care plan revision following behavior changes with individualized interventions.
- Order shatter-resistant film for front-facing secured unit windows and install it.
- Implement monitoring for the DON or designee to review the 24-hour report to identify new or increasing exit-seeking behaviors.
- Implement monitoring for the DON or designee to complete audits to verify elopement risk assessments are completed, individualized interventions are present, and documentation reflects staff implementation, then transition to routine QAPI monitoring.
Elopement from locked unit due to inadequate supervision and response to exit-seeking behaviors
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain an environment free from accident hazards for a resident with known wandering and elopement risk, resulting in an elopement through a broken bedroom window. The resident had a history of traumatic brain injury, cerebral infarction, altered mental status, and wandering, and had been admitted to a secured unit due to elopement risk. An MDS assessment earlier in the year showed the resident as cognitively intact and independently ambulatory, but a later BIMS assessment showed moderately impaired cognition. The resident’s care plan identified the need for placement on a secured unit related to traumatic brain injury and elopement risk, with interventions focused on therapeutic activities and monitoring of psychotropic medications, but did not include enhanced supervision measures in response to escalating exit-seeking behaviors. In the weeks prior to the elopement, multiple progress notes and staff interviews documented increased exit-seeking and behavioral changes after the resident returned from a home visit. On one day, progress notes recorded that the resident was up all night walking the halls, going in and out of other residents’ rooms, voicing that they did not live in the facility, and stating an intention to get out through a window. Staff documented that the resident had been seeking elopement since returning from a home visit, had been looking for ways to get out, followed staff out locked doors, and showed force when staff tried to return the resident to the unit. Another note from the same day described the resident talking loudly, being aggressive toward staff, and repeatedly expressing a desire to leave the facility. An elopement assessment documented that the resident ambulated independently, had a history of following staff and others, and had been wandering halls and standing by locked exit doors after returning from home. On the night of the elopement, camera footage showed the resident repeatedly moving between the resident’s room, the day room, and the bathroom until entering the room at approximately 3:12 a.m. and not re-emerging. Staff interviews revealed that the CNA assigned to the unit acknowledged that the resident had been trying to start a fight with another resident for two days, that the resident typically went in and out of the room throughout the night, and that staff did not normally go back to check on the resident once the resident returned to the room. The CNA reported that she did not check on the resident after the last interaction around 9:30–10:00 p.m., that she sometimes could not take breaks due to staffing, and that she dozed off for about 30 minutes during the shift. The DON later stated that the CNA reported falling asleep and not hearing the window break. Staff discovered the broken window only when an LPN returned from break around 4:25 a.m., at which point the resident was found to be missing. Law enforcement records and interviews confirmed that the facility reported the resident missing in the early morning hours and that the resident was located off-site by police after a citizen reported almost striking the resident with a vehicle. The police officer stated that the resident was found near a school approximately 1.9 miles from the facility, requiring travel across an intersection and along areas without sidewalks. The resident told police they were walking to find family. Interviews with multiple CNAs and nurses indicated that the resident had been going door to door asking how to get out, watching staff to see if they were paying attention, and walking back and forth to doors after returning from a family visit. The DON and Administrator both stated they were not aware of prior elopement attempts beyond wandering and walking back and forth, and the MDS Coordinator reported she had not been informed of the January incident in which the resident voiced a plan to escape through a window. Facility policies required staff to know the location of residents under their care and to implement care plan strategies for residents at risk of wandering or elopement, but staff interviews showed that routine checks were not performed on the resident during the night of the incident and that the resident’s escalating exit-seeking behaviors were not effectively communicated or translated into increased supervision. A police incident report and witness statements further detailed that the resident exited the building by throwing an end table through the bedroom window. The facility’s own missing resident and wandering/elopement policies stated that staff are responsible for knowing residents’ whereabouts and that care plans for at-risk residents must include safety strategies and interventions. Despite documented behaviors such as wandering, standing at locked doors, following staff out locked exits, verbalizing intent to leave, and specifically stating a plan to get out through a window, there was no evidence in the record that supervision was increased or that staff adjusted monitoring practices during periods of heightened exit-seeking. Staff interviews also revealed that for several weeks there had often been only one CNA on the locked unit at night, and that the CNA on duty the night of the elopement positioned herself in a doorway with hall lights off and later admitted to dozing off. These actions and inactions resulted in the resident being able to break the window, leave the secured unit and facility, and travel a significant distance off-site before being located and returned by police.
Failure to Follow Care-Planned Assistance and Supervision Leading to Resident Falls
Penalty
Summary
Facility staff failed to follow care-planned interventions for assistance and supervision for two residents, resulting in falls. Resident #2, admitted with Alzheimer's disease, spastic hemiplegic cerebral palsy, and neuromuscular bladder dysfunction, had a care plan requiring assistance of two staff for bathing/showering, bed mobility, personal hygiene, toilet use, and transferring. On 06/04/2025, the DON and an LPN responded to Resident #2's room and found the resident on their back on the floor after CNA #1 attempted to perform incontinent care alone, contrary to the care plan specifying a two-person assist for bed mobility, transfers, and personal hygiene. CNA #1 later stated that, upon hiring, it was not made clear how to access the electronic care plan system and that initial training on the system was brief and difficult to see. Resident #3 was admitted with spinal stenosis of the cervical region, cervical disc disorder with radiculopathy, generalized muscle weakness, and was receiving surgical aftercare following nervous system surgery. The care plan required assistance of one staff member for toileting, bathing/showering, dressing, and bed mobility, and assistance of two staff members for transferring, including use of a sliding board with two-person assist. A progress note documented that on 01/15/2026, an LPN was called to Resident #3's room and found the resident lying face down on the floor wearing a cervical collar, after the resident reported being told to dress themself. The resident later recounted that a CNA had helped them to a seated position at the edge of the bed, then left the room with another staff member while the resident attempted to dress themself, during which time the fall occurred. Interviews with multiple CNAs and facility leadership confirmed that CNAs were expected to obtain resident care instructions from the electronic care plan/Kardex system and that Resident #3 required staff assistance for all tasks except meals. CNA #2 acknowledged leaving Resident #3 unattended while assisting another staff member, despite the electronic care plan indicating the resident did not perform tasks alone. Another CNA reported sometimes being the only staff member in the room when transferring Resident #3 with a slide board, even though the care plan required two staff. The DON and Administrator stated that aides were trained one-on-one on the electronic care plans after morning huddles and that CNAs were expected to verify care requirements in the electronic care plan before providing care. The Medical Director stated it was his expectation that orders were followed as written in the care plan. Standard of practice cited requires that residents receive treatment and care in accordance with professional standards, the comprehensive person-centered care plan, and residents' choices.
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