Ridgecrest Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Jonesboro, Arkansas.
- Location
- 5504 E Johnson Ave, Jonesboro, Arkansas 72401
- CMS Provider Number
- 045327
- Inspections on file
- 43
- Latest survey
- December 12, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Ridgecrest Health And Rehabilitation during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment did not receive their 8:00 AM medications until after 11:00 AM due to an LPN being overwhelmed with tasks. The medications were administered by another staff member, contrary to facility policy, which requires the nurse who pulls the medication to administer it.
A resident with moderate cognitive impairment received medications from a Medicare Manager who did not prepare them, contrary to facility policy. The LPN who prepared the medications did not administer them, leading to a delay in the resident receiving their 8:00 AM medications. The DON confirmed the importance of the nurse who prepares medications also administering them to ensure accuracy.
Dietary staff in an LTC facility failed to practice proper hand hygiene, leading to potential cross-contamination affecting 103 residents. Observations showed staff handling clean items like glasses and plates without washing hands after touching contaminated surfaces, despite facility policies requiring handwashing to prevent foodborne illness.
The facility failed to maintain resident dignity during ADL care for two residents. One resident, moderately cognitively impaired, experienced a lack of privacy and embarrassment when CNAs did not pull the privacy curtain and passed soiled linen across their face. Another resident, severely cognitively impaired, also did not have the privacy curtain pulled during care. Both instances were acknowledged by the CNAs and the DON as inappropriate.
The facility failed to accurately document the use of an antipsychotic medication and a CPAP machine in the MDS for two residents. An MDS Nurse admitted to overlooking the antipsychotic medication, while the CPAP usage was not recorded despite being part of a resident's care plan. Both the ADON and DON confirmed the necessity of including these treatments in the MDS.
The facility failed to implement baseline care planning and enhanced barrier precautions for four residents upon admission, leading to deficiencies in care. Residents with pressure ulcers, PICC lines, and other conditions did not receive timely interventions, and necessary precautions were delayed. Interviews revealed systemic issues, including understaffing and high workloads, contributing to these deficiencies.
The facility failed to conduct proper wound assessments and follow physician orders for wound care for several residents. A resident with a traumatic amputation had inappropriate wound cleaning without a physician's order. Other residents with pressure ulcers and skin damage did not receive necessary wound evaluations. Staffing issues contributed to the delays in assessments, as new treatment nurses were in training and social services were understaffed.
The facility failed to ensure nursing staff had the necessary competencies to provide care as identified in care plans, leading to deficiencies in care planning and infection control. Several residents did not receive timely medications, and enhanced barrier precautions were not utilized. Additionally, contact isolation protocols were not followed, and a resident's CPAP usage was not documented. These issues highlight a lack of adherence to infection control measures and care planning protocols.
The facility failed to maintain the flavor, appearance, and appropriate temperature of meals, affecting residents' nutritional intake. Residents reported receiving cold and unappetizing food, with test trays confirming issues in seasoning and temperature. Unheated meal carts led to food being served at inappropriate temperatures, as confirmed by dietary staff and CNAs.
The facility failed to ensure proper infection control measures, as staff did not wear appropriate PPE or follow enhanced barrier precautions for residents on contact isolation. A resident on contact isolation had a roommate, and staff entered without PPE. Additionally, staff did not adhere to aseptic techniques during medication administration and wound care, indicating a lack of understanding and training in infection control protocols.
The facility failed to provide necessary ADL assistance for residents, particularly in maintaining hygiene and grooming. A resident with severe cognitive impairment had long, unclean fingernails despite needing assistance, while another diabetic resident had long, dirty toenails. Staff acknowledged the need for nail care, especially given the residents' conditions, but failed to provide it.
The facility failed to provide necessary pharmaceuticals for two residents during medication administration. One resident with COPD did not receive their prescribed inhaler and oral medication, while another with eye conditions did not receive their prescribed ointment. Staff acknowledged the absence of medications and the need to reorder them, highlighting a lapse in following the facility's medication ordering policy.
Two residents did not receive their prescribed medications due to unavailability during medication pass observations. One resident with COPD and asthma did not receive Advair and Montelukast, while another with eye conditions did not receive Refresh Lacri-Lube. Staff acknowledged the medications should have been available, citing reordering issues and pharmacy differences.
The facility failed to prepare and serve meals according to the planned menu and recipe, affecting residents on pureed and enhanced diets. A dietary staff member used incorrect scoop sizes for pureed oatmeal and did not follow the recipe for enhanced oatmeal, omitting key ingredients and using incorrect quantities.
A resident with a history of stroke and anxiety was found in a wheelchair with the call light out of reach, unable to call for assistance. The care plan required the call light to be within reach, but this was not adhered to. Additionally, the resident had a skin tear that was not treated promptly, causing distress. The nursing staff did not address the wound until later, leaving the resident upset and the wound exposed.
A facility failed to complete an Admission MDS in a timely manner for a resident. The MDS, required within 14 days of admission, was overdue due to staffing issues and training delays. The MDS Coordinator acknowledged the delay, citing overwork and training as contributing factors.
A resident with sleep apnea did not have their CPAP usage documented in their care plan, despite observations of the CPAP mask at the bedside and staff confirming the need for a physician's order and care plan inclusion. The facility's policy on comprehensive care plans was not followed, leading to a deficiency in addressing the resident's care needs.
The facility failed to update care plans for three residents, leading to potential negative outcomes. One resident's hearing loss was not addressed in the care plan, another's code status was inconsistently documented, and a third resident's elopement attempt was not reflected in their care plan. Staff interviews confirmed these deficiencies.
A facility failed to provide necessary foot care for a diabetic resident, resulting in long, dirty, thick, and yellow toenails. The resident, dependent on staff for care due to impaired mobility and other health issues, had not been seen by a podiatrist. Staff interviews revealed a misunderstanding of responsibilities, with CNAs not providing care due to the resident's diabetes, and nurses acknowledging the need for specialized care.
A resident with severe cognitive impairment and a history of traumatic brain injury experienced significant weight loss due to the facility's delay in implementing the RD's recommendation to increase bolus tube feedings. Despite the RD's advice to increase feedings from five to six times a day, the change was not made until several days later, resulting in a 5.2% weight loss for the month. The DON confirmed that the RD's recommendations should have been implemented within 72 hours.
A facility failed to administer enteral water flushes according to a physician's orders for a resident with a PEG tube. The resident, diagnosed with dysphagia and gastrostomy status, received only 330 mL of water flush instead of the 420 mL ordered. The DON confirmed the discrepancy, noting the resident should have received 120 mL with medications and 300 mL during the medication pass, as per the physician's order.
The facility's QAPI program failed to maintain necessary records for developing and implementing improvement plans. During a survey, the facility could not provide its QAPI plan to State surveyors. The administrator, new to the position, stated that QA committee meeting records were unavailable.
A facility failed to respect resident privacy and dignity by not knocking on doors before entering rooms. Observations showed a CNA entered multiple rooms without knocking, contrary to the facility's policy. The DON confirmed staff should knock before entering. Attempts to interview the CNA were unsuccessful.
The facility failed to ensure that licensed nurses had the necessary skills to provide individualized care for two residents. For one resident, the MDS was not completed, and care plans were outdated, while another resident's care plan lacked documentation for an indwelling catheter and a wound. Staff interviews revealed a lack of communication and training, contributing to these deficiencies.
The facility failed to implement proper infection prevention and control practices, as evidenced by multiple instances of inadequate hand hygiene by staff members during resident care. CNAs were observed not sanitizing hands between glove changes during perineal care, and a treatment nurse did not adhere to hand hygiene protocols during wound care. Additionally, there were issues with updating care plans and physician orders, contributing to the deficiencies observed.
The facility failed to provide a safe, clean, and homelike environment in a resident's room and surrounding areas. Observations showed missing paint, drywall damage, and a black substance on the floor. Staff confirmed the room's untidy state, with an unmade bed and trash present. Maintenance issues were acknowledged but not addressed, violating the facility's policy on maintaining a homelike environment.
Medication Administration Delay
Penalty
Summary
The facility failed to administer medications within the recommended time frame for a resident with moderate cognitive impairment. The resident, who had a Brief Interview for Mental Status (BIMS) score of 09, was supposed to receive 8:00 AM medications between 7:00 AM and 9:00 AM. However, due to delays, the medications were administered at 11:14 AM and 11:19 AM. The delay was attributed to the Licensed Practical Nurse (LPN) being overwhelmed with tasks, as she mentioned having '17,000 things happen.' The LPN was observed pulling medications late and leaving them on the medication cart, which were then administered by another staff member, the Medicare Manager. This practice was against the facility's policy, which states that the nurse who pulls the medication should be the one to administer it to ensure the correct medication is given to the resident. The Director of Nursing (DON) confirmed the policy and the expected time frame for medication administration.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that medications were administered by the nurse who prepared them, leading to a deficiency in medication administration for a resident with moderate cognitive impairment. On the specified date, an LPN was observed preparing medications for a resident and placing them in a medication cup on top of the medication cart. Subsequently, the Medicare Manager, without verifying the medications herself, administered them to the resident based on the LPN's assurance that they were correct. This action was contrary to the facility's policy, which requires the nurse who pulls the medications to be the one administering them to ensure accuracy. The resident involved had a Brief Interview for Mental Status (BIMS) score indicating moderate cognitive impairment and was receiving pain medication as part of their care plan. The incident occurred when the resident received their 8:00 AM medications late, at 11:14 AM and 11:19 AM, and expressed confusion about the timing of their medication. The Director of Nursing confirmed that the medications should have been administered between 7:00 AM and 9:00 AM, and emphasized the importance of the nurse who prepares the medications also administering them to the resident.
Failure in Dietary Staff Hand Hygiene
Penalty
Summary
The facility failed to ensure that dietary staff practiced proper hand hygiene, leading to potential cross-contamination affecting 103 residents. Observations revealed that dietary aides repeatedly handled clean items such as glasses, plates, and bowls without washing their hands after touching potentially contaminated surfaces. For instance, a dietary aide was seen picking up tray cards and condiments, contaminating her hands, and then handling clean glasses by their rims without washing her hands. Another aide washed her hands but then used the same tissue to turn off the faucet, contaminating her hands again before handling clean dishes. The facility's policy on preventing foodborne illness requires staff to wash their hands whenever entering or re-entering the kitchen, before contacting food surfaces, and as often as necessary to prevent cross-contamination. Despite this policy, multiple instances were observed where dietary staff failed to adhere to these guidelines, such as handling clean plates and bowls with unwashed hands after touching dirty objects. These actions were confirmed through interviews with the staff, who acknowledged the need to wash their hands after handling dirty items and before touching clean equipment.
Failure to Maintain Resident Dignity During ADL Care
Penalty
Summary
The facility failed to maintain resident dignity during the provision of Activities of Daily Living (ADL) care for two residents. For Resident #22, who was moderately cognitively impaired with a BIMS score of 11 and had a diagnosis of acute and chronic respiratory failure and chronic obstructive pulmonary disease, the deficiency occurred when Certified Nursing Assistants (CNAs) #3 and #4 did not pull the privacy curtain while performing incontinent care. Additionally, CNA #3 passed a bag of soiled linen across the resident's face, which was acknowledged by both CNAs as inappropriate. Resident #22 expressed feeling embarrassed by these actions. Similarly, Resident #66, who was severely cognitively impaired with a BIMS score of 6 and had a diagnosis of cerebral infarction and dysphagia, experienced a lack of privacy when CNAs #1 and #2 failed to pull the privacy curtain during incontinent care. Both CNAs admitted to not pulling the curtain, which was confirmed as a requirement by the Director of Nursing (DON). The DON also acknowledged that the privacy curtain should have been used for both residents to ensure their dignity was maintained.
Inaccurate MDS Documentation for Antipsychotic and CPAP Usage
Penalty
Summary
The facility failed to complete an accurate Minimum Data Set (MDS) for two residents, leading to deficiencies in their care documentation. For one resident, the MDS Nurse confirmed that an antipsychotic medication, Olanzapine, was prescribed but not documented in the MDS. The nurse admitted to possibly overlooking or miscoding the medication, acknowledging that it should have been identified in the MDS. For another resident, the facility did not document the use of a Continuous Positive Airway Pressure (CPAP) machine in the MDS, despite the resident having a diagnosis of sleep apnea and the CPAP being observed at the bedside. The resident confirmed their condition, and both the Assistant Director of Nursing and the Director of Nursing acknowledged that CPAP usage should be included in the MDS as it is part of the resident's treatment and care plan. The oversight was confirmed by the MDS Nurse, who stated that documenting CPAP usage is essential for staff awareness and resident care.
Deficiencies in Baseline Care Planning and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that baseline care planning was completed with necessary interventions upon admission for four residents, specifically concerning pressure ulcers, enhanced barrier precautions, and PICC lines. Resident #363, who had a diagnosis of malnutrition and an unstageable pressure ulcer, did not have enhanced barrier precautions set up immediately upon admission. It was observed that there was no signage or personal protective equipment available until several days after the resident's admission. Similarly, Resident #366, admitted with pressure ulcers, did not have these conditions included in the baseline care plan, and enhanced barrier precautions were not implemented until days later. Resident #367, with a diagnosis of type 2 diabetes mellitus and a traumatic partial amputation, also lacked immediate enhanced barrier precautions upon admission. The necessary signage and equipment were only set up after a delay. Additionally, Resident #371, who had endocarditis and a PICC line, did not have pressure ulcers or the PICC line included in the care plan. Enhanced barrier precautions for the PICC line were not established until after the resident's admission, and there was a lack of awareness about the resident's wounds, leading to inadequate precautions. Interviews with the MDS Nurse and the Director of Nursing revealed systemic issues, including understaffing and high workloads, which contributed to the delays in care planning and implementation of necessary precautions. The facility's policy requires comprehensive person-centered care plans to meet residents' needs, but these were not effectively developed or implemented for the residents in question, leading to deficiencies in care.
Failure to Conduct Wound Assessments and Follow Physician Orders
Penalty
Summary
The facility failed to conduct proper wound assessments and follow physician orders for wound care treatment for several residents. Resident #367 was admitted with a partial traumatic amputation of the right foot and had an order for wound vac changes on specific days. However, during an observation, an LPN used Dankins Half Strength Solution to clean the wound without a physician's order, which was confirmed by the ADON and DON as inappropriate. The APRN later clarified that a wound cleanser should have been used instead. Additionally, the facility did not complete wound and skin evaluations for Residents #363, #366, and #367. Resident #363 had a diagnosis of malnutrition and an unstageable pressure ulcer, with orders for specific wound care treatments, but no assessments were conducted. Similarly, Resident #366, diagnosed with paralytic syndrome and other conditions, had orders for treating moisture-associated skin damage, but no evaluations were completed. Resident #371 had incomplete skin and wound evaluations, with no further assessments conducted since admission. Interviews with facility staff revealed that the lack of wound assessments was due to staffing issues, as new treatment nurses were in training after the previous ones quit unexpectedly. The MDS Coordinator confirmed that wound assessments were overdue for several residents, and the Quality-of-Life Specialist acknowledged delays in admission assessments due to understaffing in social services. The DON emphasized the importance of wound assessments for determining treatment plans and ensuring proper wound care.
Deficiencies in Care Planning and Infection Control
Penalty
Summary
The facility failed to ensure that nursing staff had the necessary competencies and skills to provide care and respond to individualized needs as identified in care plans. This deficiency was observed in several areas, including the failure to complete baseline and comprehensive care plans with interventions upon admission for pressure ulcers, enhanced barrier precautions, CPAP, elopement, and PICC line for multiple residents. Additionally, enhanced barrier precautions were not utilized upon admission or during care for several residents, and wound assessments were not set up to ensure healing and improvement of wounds. The facility also failed to ensure that medications were ordered timely, resulting in residents not receiving physician-ordered medications at scheduled times. For instance, a resident with COPD did not receive their prescribed inhalation aerosol and oral tablet due to a delay in reordering. Another resident did not receive their prescribed eye ointment and received an incorrect amount of water flush through a PEG tube, as the medication was last ordered months prior and required a manual reorder. Furthermore, the facility did not adhere to contact isolation protocols, as evidenced by a resident on contact isolation having a roommate and staff entering the room without appropriate PPE. Additionally, a resident's CPAP usage was not documented in their care plan or physician's orders, and another resident's attempted elopement was not reflected in their care plan. These deficiencies highlight a lack of adherence to infection control measures and care planning protocols, which are critical for ensuring resident safety and well-being.
Deficiency in Food Preparation and Serving Temperatures
Penalty
Summary
The facility failed to ensure that food was prepared and served in a manner that maintained its flavor, appearance, and appropriate temperature, affecting the palatability and nutritional intake of residents. Observations and interviews revealed that residents frequently received meals that were cold and unappetizing. For instance, one resident expressed dissatisfaction with the food, describing it as frequently cold and overly spicy. Another resident questioned the quality of the macaroni and cheese, stating it was cold and unpalatable. A test tray revealed issues with the food's seasoning and temperature, with the cheese forming an unpleasant film and the mashed potatoes lacking salt. The deficiency was further evidenced by the delivery of unheated meal carts to various halls, resulting in food items being served at inappropriate temperatures. For example, milk was recorded at 43.7 and 45.5 degrees Fahrenheit, and fried chicken was served at 114.8 degrees Fahrenheit, all of which are outside the recommended temperature ranges for safe and appetizing consumption. These findings were confirmed by dietary staff and CNAs who checked the temperatures of the food items after delivery, highlighting a systemic issue in the facility's food service process.
Infection Control Deficiencies in PPE Use and Isolation Practices
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were in place for residents on contact isolation and enhanced barrier precautions. Resident #31, who was on contact isolation due to a history of recurring urinary tract infections, was observed to have a roommate, which is against standard infection control practices. Staff members, including a registered nurse and certified nurse aides, were seen entering the room without wearing the appropriate personal protective equipment (PPE) such as gowns, masks, and gloves, despite the presence of contact precaution signs on the door. Interviews with staff revealed a lack of awareness and understanding of the necessity of PPE in preventing the spread of infection. Additionally, the facility did not ensure that staff adhered to enhanced barrier precautions for residents requiring such measures. For instance, during medication administration and wound care for residents #363, #366, #367, and #371, staff failed to wear gowns and sanitize their hands as required. Observations showed that staff did not follow proper aseptic techniques, such as changing gloves and performing hand hygiene between tasks, which are critical to preventing cross-contamination and infection. The report also highlights deficiencies in the facility's handling of residents with specific medical needs, such as those with percutaneous endoscopic gastrostomy (PEG) tubes and continuous positive airway pressure (CPAP) devices. Staff were observed not wearing PPE or sanitizing hands during PEG medication administration and tube feeding for Resident #28. Furthermore, CPAP face masks were not stored properly when not in use, increasing the risk of contamination. These lapses in infection control practices indicate a systemic issue with staff training and adherence to established protocols, as evidenced by the staff's own admissions of not understanding enhanced barrier precautions and the need for more education on infection control measures.
Failure to Provide Adequate ADL Assistance for Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for residents who required it, specifically in maintaining good hygiene and grooming. Resident #71, who has severe cognitive impairment and requires assistance with personal care, was observed with long, jagged fingernails that had a dark gritty substance underneath. Despite the care plan indicating that nail care should be performed on bath days and as needed, the resident's nails remained untrimmed and uncleaned over several days. Staff, including a Licensed Practical Nurse and a Certified Nursing Assistant, acknowledged the need for nail care, especially given the resident's diabetic condition, which increases the risk of infection. Similarly, Resident #22, who is moderately impaired and dependent on staff for ADLs, was found with long, dirty toenails. The resident, diagnosed with diabetes and other health conditions, did not receive appropriate nail care due to their diabetic status, which requires a nurse to perform such tasks. Both the Assistant Director of Nursing and the Director of Nursing confirmed that a nurse should provide nail care for diabetic residents, yet this was not done, leading to the deficiency in care.
Failure to Provide Necessary Pharmaceuticals
Penalty
Summary
The facility failed to ensure that all pharmaceuticals were available for residents during medication administration, as observed in two separate cases. Resident #31, who has a medical history of asthma, chronic obstructive pulmonary disease (COPD), emphysema, wheezing, and chronic cough, did not receive their prescribed medications, Advair HFA Inhalation Aerosol and Montelukast Sodium, during a medication administration observation. The registered nurse responsible for administering the medication acknowledged the absence of these medications and stated that they had just reordered them. Similarly, Resident #28, diagnosed with Dry Eye Syndrome and other eye-related conditions, did not receive their prescribed Refresh Lacri-Lube Ointment. The Assistant Director of Nursing (ADON) noted that the medication had not been reordered since March and mentioned the need to call a different pharmacy to reorder it. The facility's policy requires medications to be ordered in advance, but this was not adhered to, resulting in the unavailability of necessary medications for the residents.
Medication Errors Due to Unavailable Prescriptions
Penalty
Summary
The facility failed to ensure physician orders were followed, resulting in medication errors for two residents. Resident #31, who has a history of asthma, COPD, emphysema, wheezing, and chronic cough, did not receive prescribed medications, Advair HFA Inhalation Aerosol and Montelukast Sodium, during a medication pass observed on 7/30/2024. The Registered Nurse responsible for administering the medication acknowledged that the medications should have been available and stated that they had just reordered them. The Medication Administration Record confirmed that the resident did not receive the medications as prescribed. Similarly, Resident #28, diagnosed with dry eye syndrome and other eye-related conditions, did not receive the prescribed Refresh Lacri-Lube Ointment for lagophthalmos. The Assistant Director of Nursing noted that the medication had not been reordered since March and mentioned difficulties in ordering due to the resident using a different pharmacy. During the observation of medication administration, it was confirmed that the resident did not receive the ointment. The ADON acknowledged that medications should be available when due but indicated that the issue was affecting her time management.
Failure to Follow Meal Preparation and Serving Guidelines
Penalty
Summary
The facility failed to ensure that meals were prepared and served according to the planned written quantified recipe and menu, which compromised the nutritional needs of residents. During a breakfast observation, it was noted that residents on pureed diets were served a smaller portion of oatmeal than specified. Dietary staff used a #16 scoop (1/4 cup) instead of the required #8 scoop (1/2 cup) as per the facility menu. This discrepancy was confirmed when the dietary staff member admitted to using the incorrect scoop size and serving only one portion to each resident. Additionally, the facility did not adhere to the recipe for enhanced oatmeal intended for residents requiring enhanced food diets. The dietary staff member responsible for preparing the meal did not follow the recipe, omitting key ingredients such as margarine and using incorrect quantities of brown sugar and dry milk. When questioned, the staff member admitted to not consulting the recipe before preparation. This failure to follow the specified recipe and menu had the potential to affect the nutritional intake of residents receiving pureed and enhanced diets.
Failure to Ensure Call Light Accessibility and Timely Wound Care
Penalty
Summary
The facility failed to ensure that the needs and preferences of a resident were reasonably accommodated, specifically by not ensuring the call light was within reach. The resident, who had a history of paralytic syndrome affecting the right side due to a stroke, anxiety disorder, and major depressive disorder, was observed in a wheelchair with the call light attached to the bed rail on the right side, out of reach. The resident was unable to self-propel to reach the call light and had been in this position for approximately forty minutes. The care plan for the resident explicitly stated that the call light should be within reach and that the resident required prompt responses to requests for assistance. Additionally, the resident had a skin tear on the left arm that required treatment, which was not addressed promptly. The resident expressed distress and was tearful while waiting for the nursing staff to treat the skin tear. The surveyor observed that the nursing staff did not attend to the skin tear until later, leaving the resident upset and the wound exposed for an extended period. This incident highlights a failure in the facility's responsibility to accommodate the resident's needs and ensure timely medical attention.
Delayed Completion of Admission MDS
Penalty
Summary
The facility failed to complete an Admission Minimum Data Set (MDS) in a timely manner for a resident. The MDS, which was supposed to be completed within 14 days of the resident's admission, was started on July 8, 2024, with an Assessment Reference Date of July 11, 2024, but was 18 days overdue for completion as of July 29, 2024. The facility's policy requires the Assessment Coordinator to ensure timely assessments, but due to staffing issues and training delays, the MDS was not completed on time. MDS Coordinator #19 acknowledged the delay, citing that both she and MDS Coordinator #20, who was still in training, were overworked, leading to the oversight.
Deficiency in Comprehensive Care Plan for Resident with Sleep Apnea
Penalty
Summary
The facility failed to ensure that a comprehensive care plan addressed and individualized appropriate care and services for a resident diagnosed with sleep apnea. The resident's admission record indicated a diagnosis of sleep apnea, yet the care plan did not document the use of a Continuous Positive Airway Pressure (CPAP) machine. Observations by the surveyor revealed that the CPAP mask was left on the bedside table without a storage bag, and there was no physician's order for CPAP usage documented in the resident's order summary report. Additionally, the Admission Minimum Data Set (MDS) inaccurately documented that the resident did not use a CPAP. Interviews with facility staff, including the Assistant Director of Nursing, Director of Nursing, and MDS Nurse, confirmed that the CPAP machine usage should have been included in the care plan as it is a treatment and part of the resident's plan of care. The facility's policy on comprehensive person-centered care plans emphasized the need for measurable objectives and timetables to meet residents' needs, which was not adhered to in this case. The lack of documentation and inclusion of CPAP usage in the care plan represents a deficiency in meeting the resident's care needs.
Failure to Update Care Plans for Residents' Needs
Penalty
Summary
The facility failed to update person-centered care plans to accurately reflect the needs of three residents, leading to potential negative outcomes. For one resident with moderate hearing loss, the care plan did not include any interventions to address this issue, despite confirmation from an Advanced Practice Nurse and documentation in the Minimum Data Set (MDS) indicating the impairment. Another resident expressed a desire to be a Do Not Resuscitate (DNR), but the care plan inconsistently documented both full code and DNR statuses, creating confusion among staff about the resident's true code status. Additionally, the facility did not update the care plan for a resident who attempted to elope from the facility, despite documentation of the incident in nursing progress notes. The resident, diagnosed with Alzheimer's disease and dementia with agitation, was able to exit the building, but the care plan did not reflect this elopement attempt or include interventions to prevent future occurrences. Interviews with staff confirmed the lack of updates to the care plan, which is necessary to protect the resident and inform staff of the risks.
Failure to Provide Necessary Foot Care for Diabetic Resident
Penalty
Summary
The facility failed to provide necessary foot and toenail care for a resident who was dependent on staff for such care. The resident, who had a history of acute and chronic respiratory failure, chronic obstructive pulmonary disease, and type 2 diabetes mellitus with a foot ulcer, was observed to have long, dirty, thick, and yellow toenails. The resident's care plan indicated a self-care performance deficit related to impaired mobility, morbid obesity, and dementia, requiring staff assistance for activities of daily living. During an observation, a CNA stated that she did not provide foot/toenail care for the resident because the resident was diabetic. Both the ADON and DON confirmed that a nurse should provide nail care for diabetic residents. Upon inspection, the DON noted the resident's foot appeared puffy and stiff, with toenails that were thick, yellow, long, and dirty. It was also revealed that a podiatrist had not visited the resident, indicating a lack of appropriate foot care management for the resident.
Delay in Implementing RD Recommendations for Tube Feeding
Penalty
Summary
The facility failed to implement the Registered Dietitian's (RD) recommendations in a timely manner for a resident with severe cognitive impairment and a history of post-traumatic seizures and traumatic brain injury. The resident was admitted with a care plan that included regular evaluations by the RD to monitor nutritional intake and make necessary adjustments to tube feeding. On a recent RD visit, it was noted that the resident had lost 8.9 pounds over a short period, prompting the RD to recommend increasing the resident's bolus tube feedings from five to six times a day to address the weight loss. Despite the RD's recommendation on 7/25/2024, the facility did not increase the bolus feedings until 7/30/2024, which was beyond the 72-hour window that the Director of Nursing (DON) stated was the expected timeframe for implementing such recommendations. This delay was confirmed through interviews with the Assistant Director of Nursing (ADON) and the DON, who acknowledged that the increase should have occurred sooner. As a result, the resident experienced a significant weight loss of 5.2% for the month of July, indicating a failure to provide adequate nutrition in a timely manner.
Failure to Administer Enteral Water Flush Per Physician's Orders
Penalty
Summary
The facility failed to administer enteral water flushes according to the physician's orders for a resident with a Percutaneous Endoscopic Gastrostomy (PEG) tube. Resident #28, who has diagnoses of dysphagia and gastrostomy status, was observed during a medication pass where the total water flush administered was 330 milliliters (mL), which was less than the 420 mL ordered by the physician. The physician's order specified 60 mL of water flush before and after medication administration and an additional 300 mL of enteral water flush, but the resident only received 210 mL of water flush during the medication pass. The Director of Nursing confirmed that the resident should have received 120 mL of water flush with medications and 300 mL of water flush during the medication pass, as per the physician's order. The facility's policy on enteral tube feeding via syringe, revised in November 2018, requires verification of a physician's order and review of the resident's care plan. However, the facility did not adhere to these standards, resulting in the deficiency observed by the surveyor.
QAPI Records Unavailable During Survey
Penalty
Summary
The facility's Quality Assurance Performance Improvement Program (QAPI) failed to maintain records of their program, which are necessary for developing and implementing effective improvement plans to address identified areas of concern. During a recertification survey, the facility was unable to provide its QAPI plan to the State surveyors upon request. The administrator, who had been in the position for a week, stated that he was unable to provide records of the Quality Assurance (QA) committee meetings because they could not be found.
Failure to Respect Resident Privacy and Dignity
Penalty
Summary
The facility failed to honor residents' rights to privacy and dignity by not knocking on doors before entering their rooms. Observations revealed that a Certified Nursing Assistant (CNA) entered multiple resident rooms without knocking, which is against the facility's policy on resident rights. The policy, revised in December 2016, mandates that employees treat all residents with kindness, respect, and dignity, including respecting their privacy and confidentiality. During the observations, CNA #4 entered rooms 609, 610, 612, and 613 without knocking, turned on lights, and interacted with residents without explaining her actions. The Director of Nursing (DON) confirmed that staff should knock before entering a resident's room. Attempts to interview CNA #4 were unsuccessful as she left the facility before the interview could be conducted and did not return calls. This lack of adherence to the facility's policy on resident rights was observed multiple times, indicating a systemic issue with respecting residents' privacy and dignity.
Deficiencies in Resident Care Due to Incomplete Assessments and Care Plans
Penalty
Summary
The facility failed to ensure that licensed nurses possessed the necessary knowledge, competencies, and skills to provide individualized care for residents, as evidenced by deficiencies in the care of two residents. For Resident #6, the Minimum Data Set (MDS) was not completed according to the guidelines, and care plans were not updated to reflect the resident's current physician orders and needs. The MDS Coordinator admitted to not being trained on Medicare and managed MDS, which contributed to the incomplete care plans. Additionally, the Medicare Manager was on vacation, and the MDS Coordinator did not fill in, leading to delays in completing necessary assessments. Resident #7's care was also compromised due to a lack of updated care plans and failure to follow physician orders. The resident had an indwelling catheter, but there was no documentation of catheter care, and the care plan did not address the catheter or the right gluteus wound. The treatment nurse, who was new to the role, was unaware of the need for documentation and did not update the care plans or physician orders as required. The Director of Nursing (DON) confirmed that the treatment nurse was responsible for care planning and updating orders, but these tasks were not completed, resulting in inadequate care for the resident. Interviews with facility staff revealed a lack of communication and training, contributing to the deficiencies. The LTC MDS Coordinator and the Medicare Manager were responsible for completing and submitting the MDS, but both acknowledged being behind on their duties. The treatment nurse and the MDS Coordinator did not collaborate effectively, leading to incomplete care plans and unaddressed resident needs. The facility's policies on care planning, wound care, and catheter care were not followed, resulting in a failure to provide appropriate care for the residents.
Inadequate Hand Hygiene and Infection Control Practices
Penalty
Summary
The facility failed to implement proper infection prevention and control practices, as evidenced by multiple instances of inadequate hand hygiene by staff members during resident care. Certified Nursing Assistant (CNA) #4 was observed entering and exiting resident rooms without sanitizing hands before and after glove use, particularly during perineal care and other personal care tasks. This lack of hand hygiene was noted during interactions with a resident diagnosed with functional quadriplegia, who required assistance with personal care. The resident reported not being changed since midnight, and the surveyor observed soiled briefs and underpads, indicating neglect in care. Further observations revealed that CNA #1 and CNA #2 also failed to perform hand hygiene appropriately during perineal care. CNA #1 was seen changing gloves multiple times without sanitizing hands, touching various surfaces and the resident with the same gloves, and handling clean and dirty items interchangeably. This improper practice was consistent throughout the care process, including dressing the resident and using a mechanical lift for transfer, without changing gloves or sanitizing hands. Additionally, the treatment nurse responsible for wound care on another resident did not adhere to hand hygiene protocols. The nurse was observed handling wound care supplies and performing wound dressing changes without sanitizing hands between glove changes or after completing tasks. The nurse also failed to update care plans and physician orders accurately, as evidenced by outdated treatment orders and missing documentation for skin and wound evaluations. The facility's policies on infection control and hand hygiene were not followed, contributing to the deficiencies observed during the survey.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in room [ROOM NUMBER] and surrounding areas. Observations by the surveyor revealed missing paint and drywall on the walls, a black substance on the floor near the baseboards, and a cracked and bubbled ceiling near the light above the entrance. Additionally, personal items such as an open bag and cups were left unattended in the hallway near the room. Interviews with staff confirmed the room's untidy state, with an unmade bed and trash on an under pad, and the presence of a yellow substance, possibly soda, on the bed. The Maintenance Assistant acknowledged that the room had not been reported for maintenance, despite visible damage likely caused by a wheelchair and a bed. The assistant noted that the damage around the light was due to a previous winter incident involving a burst pipe. The facility's policy on providing a homelike environment was not adhered to, as evidenced by the unsanitary and uncomfortable conditions observed in the room and hallways.
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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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