River Ridge Rehabilitation And Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wynne, Arkansas.
- Location
- 1100 East Martin Drive, Wynne, Arkansas 72396
- CMS Provider Number
- 045157
- Inspections on file
- 27
- Latest survey
- June 6, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at River Ridge Rehabilitation And Care Center during CMS and state inspections, most recent first.
The facility did not maintain adequate nursing staff as outlined in its own assessment, resulting in numerous shifts with insufficient coverage. This led to delays in resident care, unmade beds, missed assistance with meals, multiple falls (including some with major injury), and repeated late administration of insulin to a resident. Staff interviews confirmed ongoing staffing shortages and their impact on resident care.
An LPN failed to administer multiple ordered medications, including antihistamines, vitamins, and other treatments, to four residents during a medication pass. The omissions were not initially recognized by the LPN, who had marked the medications as given in the MAR. This resulted in a medication error rate of 26.19%, significantly exceeding the acceptable threshold.
Surveyors identified that food storage and handling practices were not followed, including the presence of dented cans, unrefrigerated opened beverages, unsealed dry goods, and expired food items on shelves. These actions were not in accordance with facility policy for sanitary food service.
A resident with severe cognitive and physical impairments, who required substantial assistance with dressing and had a documented preference for wearing a white T-shirt, was repeatedly observed in a hospital gown despite having personal clothing available. Facility leadership and staff acknowledged that this failure to follow the care plan did not honor the resident's dignity or rights.
A resident with COPD and chronic respiratory failure was given supplemental oxygen at flow rates higher than ordered by the physician, despite being unable to adjust the oxygen concentrator independently. Staff failed to follow the care plan and facility policy, resulting in the resident receiving oxygen at four and five liters per minute instead of the prescribed two liters per minute as needed.
A resident who was dependent on staff for transfers and required to be up in a wheelchair three times a week did not have this physician-ordered intervention included or implemented in their care plan or Kardex. Despite requests and family concerns, staff did not assist the resident as ordered, and documentation failed to reflect the required care.
A resident who was dependent on staff for transfers and at risk for skin breakdown was not assisted to a chair as ordered by the physician, despite making direct requests to staff. Staff failed to follow the care plan and physician orders, did not document required interventions, and left the resident in bed for an extended period, contrary to facility policy and standard care practices.
The facility's kitchen was found to have multiple sanitation issues, including unclean and damaged surfaces, uncovered food items, and improper hand hygiene by dietary staff. Expired food items were also found in storage, indicating a lack of adherence to food safety standards.
The facility failed to prepare and serve meals according to the planned menu, affecting residents on mechanical soft, pureed, and super calorie diets. The dietary cook prepared insufficient servings of meatloaf, omitted gravy for a pureed diet, and served smaller portions of super cereal. Additionally, water was used for pureeing food instead of nutrient-preserving liquids like milk or broth.
The facility failed to ensure meals were served in a manner that conserved nutritive value and maintained appearance, and that food items were stored and served at safe and appetizing temperatures. Residents reported receiving cold food, and observations revealed that the dietary cook used tap water instead of stock or milk to puree food items, resulting in bland meals. Additionally, food temperatures on meal trays were below acceptable levels, compromising the palatability and safety of the food.
The facility failed to ensure pureed food items were blended to a smooth, lump-free consistency for residents requiring pureed diets. Observations on two separate days revealed lumpy and clumpy pureed meatloaf, cubed steak, and cabbage, confirmed by the Activity Director and a CNA.
A resident with multiple health issues, including morbid obesity and a urinary tract infection, did not receive proper incontinent care. Two CNAs cleaned only the backside after an incontinent episode, neglecting the perineal area, which was confirmed by an LPN and the DON. This failure to follow facility policy put the resident at risk for infections and skin breakdown.
The facility failed to assist a resident with proper positioning, leading to difficulty in reaching a meal tray. Despite the resident's need for substantial assistance due to medical conditions, staff did not position the resident correctly, and the facility lacked a policy on positioning residents in bed.
The facility failed to ensure a leg strap was in place to prevent trauma from an indwelling catheter for a resident with retention of urine and reflux uropathy. Despite the care plan's instructions, the catheter was not secured, and staff confirmed the absence of a secure device. The DON and Administrator acknowledged the need for a leg strap, but no specific policy was in place.
Expired medications, including a hypodermic needle, a liquid multivitamin/mineral supplement, and Lorazepam Intensol syringes, were found in the medication storage room. LPNs confirmed the expiration dates and removed the items, with the DON confirming the expiration of the syringes.
A facility failed to perform proper hand hygiene during incontinence care for a resident with multiple health issues, including morbid obesity and a urinary tract infection. The CNA did not follow hand hygiene protocols before applying gloves, between glove changes, or after removing gloves, as confirmed by the CNA, an LPN, and the DON.
A resident with urinary retention and an indwelling catheter was prescribed Macrobid for a UTI based on symptoms that did not meet the facility's criteria. The ADON/IP confirmed the criteria were not met, but the prescribing physician proceeded with the antibiotic prescription based on the appearance of the urine and the diagnosis of urinary retention.
A resident with a stage 4 pressure ulcer did not receive wound care treatments as ordered, leading to the deterioration of the wound. The resident, with multiple health issues, missed 13 treatments over April and May. The wound worsened, resulting in a hospital admission for sepsis and a urinary tract infection. Facility staff confirmed the absence of a dedicated wound care nurse, and the Director of Nursing noted that unsigned treatments in the TAR indicated they were not completed.
Failure to Maintain Sufficient Nursing Staff per Facility Assessment
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by not following its own facility assessment staffing guidelines for 74 out of 87 shifts reviewed over a one-month period. The facility's assessment outlined specific staffing requirements per shift, including the number of RNs, LPNs, CNAs, and other support staff needed to care for residents with a wide range of diagnoses and care needs, such as psychiatric disorders, heart and circulatory conditions, neurological disorders, and residents requiring assistance with activities of daily living. Despite these guidelines, staffing records showed that many shifts were either partially or completely unstaffed according to the facility's own standards. Observations and interviews with staff revealed that the lack of adequate staffing led to delays in meeting residents' needs. CNAs reported that residents often had to wait a long time for assistance, and that beds were left unmade and rooms were messy, particularly on weekends. Dietary staff noted that residents complained about their food getting cold while waiting for help, and that food trays were sometimes returned untouched, possibly due to the absence of staff to assist residents to the dining room. Record reviews further indicated that the insufficient staffing contributed to care issues, including multiple resident falls, some resulting in major injury, and medication administration delays. For example, one resident with orders for both long-acting and fast-acting insulin received doses late on 16 occasions during the month, sometimes up to four hours past the scheduled time. The DON confirmed that the facility did not use temporary or contract staff and acknowledged the ongoing staffing challenges.
Medication Error Rate Exceeds Acceptable Threshold During Medication Pass
Penalty
Summary
During a medication administration observation, an LPN failed to administer multiple ordered medications to four residents during a morning medication pass. Specifically, the LPN did not provide antihistamines to two residents, and omitted antihistamine, laxative solution, and eye drops for another resident. For a fourth resident, the LPN failed to administer vitamin C, ferrous sulfate elixir, a multivitamin, protein oral liquid, zinc, and a laxative. These omissions were observed during 42 medication administration opportunities, resulting in 11 medication errors and a medication error rate of 26.19%. The LPN initially indicated that all medications due had been administered, but upon review of the Medication Administration Record (MAR), confirmed that the omitted medications were not given, stating she did not scroll to see those orders. The MAR had been marked as if the medications were administered. The facility's policy requires medications to be administered according to prescriber orders and proper medication administration practices. The administrator confirmed that staff are expected to follow these procedures.
Deficient Food Storage and Handling Practices
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food storage and handling practices during a tour of the kitchen and pantries with the Dietary Manager. Eight dented cans of various food items were found on shelves intended for resident use, despite the Dietary Manager stating that such cans should be discarded due to the risk of metal shavings. An opened bottle of lemon flavor sweet tea was found unrefrigerated after opening, contrary to proper storage requirements. Additionally, an opened bag of rice was left unsealed and exposed to air. Two bags of corn chips and several seasoning/spice bottles, a bottle of steak sauce, and three grated cheese containers were all found with use-by dates that had already passed, indicating expired food items were not discarded as required. These findings were in direct violation of the facility's policy to store, prepare, distribute, and serve food under sanitary conditions.
Failure to Honor Resident's Dignity by Not Dressing in Preferred Attire
Penalty
Summary
A deficiency was identified when staff failed to honor a resident's right to dignity by not dressing the resident in their preferred attire, as specified in the care plan. The resident, who had a history of hemiplegia and hemiparesis following a cerebral infarction and was severely impaired in daily decision making, required substantial assistance with dressing. The care plan clearly indicated that the resident preferred to wear a white T-shirt at all times and required staff assistance for dressing due to cognitive and physical impairments. Despite these documented preferences and needs, the resident was repeatedly observed lying in bed wearing a hospital gown on multiple occasions. Interviews with the resident's representative confirmed that the resident was always seen in a hospital gown during visits, even though personal clothing was available at the facility. Facility leadership, including the DON and Administrator, acknowledged that the resident should have been dressed in regular clothes as per the care plan and that failing to do so did not honor the resident's dignity or rights. Staff also recognized that keeping a resident in a hospital gown was against resident rights, as outlined in facility policy.
Failure to Administer Supplemental Oxygen per Physician Orders
Penalty
Summary
A resident with diagnoses of chronic obstructive pulmonary disease (COPD) and chronic respiratory failure was observed receiving supplemental oxygen at flow rates higher than those ordered by the physician. Multiple observations showed the resident receiving oxygen at four and five liters per minute via nasal cannula, while the physician's order specified oxygen at two liters per minute as needed. The resident's care plan instructed staff to check oxygen settings and provide oxygen as ordered, referencing the physician's orders. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that the oxygen concentrator was set above the ordered rate and that the resident was unable to adjust the flow independently due to physical limitations. The facility's policy required staff to check the physician's order for liter flow and set the flow meter accordingly, but this was not followed, resulting in the resident receiving oxygen at a higher rate than prescribed.
Failure to Implement Physician-Ordered Transfers in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that included all ordered care for a resident who was dependent on staff for transfers and required to be up in a wheelchair three times a week, as ordered by the physician. Observations revealed that despite the resident's request to be transferred to a chair, staff did not provide the required assistance during the observed period. The care plan and Kardex did not include the physician's order for the resident to be up in a wheelchair three times weekly, and there was no documentation of this intervention being carried out. Interviews with staff confirmed that they relied on the care plan and Kardex for resident care instructions, but these documents lacked the necessary information regarding the transfer order. The resident was cognitively intact and required maximum to total assistance for most activities of daily living, including transfers, as documented in the Minimum Data Set. Family members reported that the resident was not being transferred to a chair as ordered and expressed concerns about the resident being left in bed for extended periods. Staff interviews indicated a lack of training on repositioning and an absence of documentation or interventions in the care plan to address the physician's order for regular transfers to a chair. This failure to include and implement the ordered care in the resident's care plan led to the deficiency.
Failure to Implement Physician's Order for Resident Transfer to Chair
Penalty
Summary
A deficiency occurred when staff failed to implement a physician's order for a resident to be transferred to a chair three times a week during the day shift. Despite the resident being cognitively intact and able to request assistance, staff did not respond to the resident's request to be gotten up to a chair during the observed period. The resident pressed the call light and directly asked a CNA for help, who stated they would return with assistance but did not follow through. Over a two-hour and seventeen-minute observation period, no staff entered the room to assist the resident, and the resident remained in bed throughout. Record reviews confirmed that the resident was dependent on staff for all transfers and required a two-person assist with a mechanical lift, as documented in the care plan and physician orders. However, there was no documentation of the resident being transferred to a chair as ordered, nor was this intervention included in the Kardex. Interviews with staff revealed a lack of training on repositioning and inconsistent documentation practices regarding position changes and transfers. Staff indicated that residents should be turned every two hours and assisted to a chair upon request, but these practices were not consistently followed or documented for this resident. Family interviews corroborated that the resident was not routinely gotten up to a chair as ordered, and concerns were raised about the resident being left on their back for extended periods. Facility leadership acknowledged that residents should not remain in one position for hours and that failure to assist with transfers could lead to negative outcomes. Facility policies reviewed emphasized the importance of frequent repositioning and activity to prevent pressure ulcers, but these were not adhered to in the resident's care.
Sanitation and Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain a sanitary environment in the kitchen, as evidenced by multiple observations of unclean and damaged surfaces. The kitchen floor, walls, and ceiling tiles were found to be stained, chipped, greasy, and peeling, with rust and discoloration in various areas. Additionally, the ice machine and milk refrigerator had visible residue and mildew, and the walk-in refrigerator and freezer contained uncovered and unsealed food items. These conditions were observed during a survey and were confirmed through interviews with dietary staff and the Activity Director. Dietary staff were also observed failing to follow proper hand hygiene protocols. On several occasions, dietary aides and cooks handled clean equipment and food items without washing their hands after touching dirty objects or surfaces. This included handling dishes, glasses, and food items directly with their bare hands, which could lead to cross-contamination and potential foodborne illness. The staff acknowledged their failure to wash hands when questioned by the surveyor. Expired food items were found in the dry storage room, including parmesan cheese without open dates and a bottle of Hershey's syrup that should have been refrigerated after opening. Additionally, expired gluten-free thousand island dressing was found on a shelf. These practices indicate a lack of adherence to food safety standards and proper stock rotation, further compromising the safety and quality of food served to the residents. The facility's handwashing policy was not being followed, as staff did not consistently wash their hands before starting food-related tasks or after touching dirty equipment and surfaces.
Deficiencies in Meal Preparation and Serving
Penalty
Summary
The facility failed to ensure meals were prepared and served according to the planned written menu, and recipes were followed to meet the nutritional needs of the residents. During lunch, the dietary cook prepared only 8 servings of meatloaf for residents on mechanical soft diets, instead of the required 15 servings. Additionally, a resident on a pureed diet did not receive the specified 2 ounces of gravy with mashed potatoes. The dietary cook admitted to not seeing the requirement for gravy on the menu. Furthermore, during breakfast, residents on super calorie diets were served only a half-cup portion of super cereal instead of the specified one cup. The dietary cook confirmed using a 1/2 cup scoop to serve the cereal, contrary to the menu specifications. The surveyor also inquired about the liquid used for pureeing food items, and the dietary cook stated that she used water. The cook acknowledged that using milk or broth would be better for maintaining nutrient content and taste. These deficiencies in meal preparation and serving had the potential to affect the nutritional intake of residents on mechanical soft, pureed, and super calorie diets.
Failure to Maintain Nutritive Value and Temperature of Meals
Penalty
Summary
The facility failed to ensure that meals were served in a manner that conserved nutritive value and maintained appearance, and that food items were stored and served at safe and appetizing temperatures. During the observation, it was noted that residents receiving meal trays in their rooms consistently received cold food. For instance, Resident #34, who is cognitively intact, reported that the food was always cold when it arrived. Similarly, Resident #13, who has moderately impaired cognitive function, confirmed that their meals also arrived cold. The dietary cook was observed using tap water instead of the recommended stock or milk to puree food items, which resulted in bland and less nutritious meals. The Activity Director confirmed that the pureed meatloaf tasted bland and required more salt, indicating a failure to follow the facility's recipes properly. Additionally, the temperature of food items on meal trays delivered to various halls was found to be below acceptable levels. For example, scrambled eggs and ground sausage with gravy were served at temperatures ranging from 91 to 105 degrees Fahrenheit, and milk was served at temperatures as high as 55 degrees Fahrenheit. These temperatures are not within the safe and appetizing range, which compromises the palatability and safety of the food. The use of unheated carts for meal delivery further exacerbated the issue, as observed during the delivery of breakfast trays to different halls. The dietary cook acknowledged that using water to puree food items would not taste as good as using milk or broth, further highlighting the facility's failure to maintain the nutritive value and palatability of the meals served to residents.
Failure to Ensure Smooth Pureed Food Consistency
Penalty
Summary
The facility failed to ensure pureed food items were blended to a smooth, lump-free consistency for residents requiring pureed diets. On 05/28/2024, a dietary cook prepared pureed meatloaf that was observed to be lumpy and not smooth. The Activity Director confirmed the meatloaf appeared chunky. On 05/29/2024, pureed cubed steak and cabbage served at lunch were also found to contain clumps and were not smooth. The Activity Director described the cubed steak as thick and stringy, and a Certified Nursing Assistant described the meat and cabbage as thick and gritty. These observations were made during two meals and had the potential to affect one resident on a pureed diet.
Failure to Perform Proper Incontinent Care
Penalty
Summary
The facility failed to perform proper incontinent care for Resident #9, who was admitted with diagnoses including morbid obesity, dysuria, and a urinary tract infection. The resident, who was cognitively intact with a BIMS score of 14, required substantial assistance with toileting hygiene. During an observation, two CNAs cleaned only the backside of the resident after an incontinent episode, neglecting to clean the perineal area. This was confirmed by both CNAs and an LPN present in the room, who acknowledged that the front should have been cleaned to prevent potential infections and skin breakdown. The Director of Nursing confirmed that proper incontinent care should include cleaning from the top of the buttocks to the thighs, between the thighs, and the front to prevent skin breakdown and urinary tract infections. The facility's policy on perineal care also indicated that cleaning should be done from front to back to prevent contamination. The failure to follow these guidelines resulted in incomplete incontinent care for Resident #9, putting the resident at risk for further health complications.
Failure to Assist Resident with Proper Positioning
Penalty
Summary
The facility failed to ensure proper assistance in positioning and repositioning for Resident #26, who required substantial assistance due to diagnoses including cerebral infarction, retention of urine, and obstructive and reflux uropathy. The resident's care plan indicated the need for maximal assistance with bed mobility. However, during an observation, the resident was found lying in bed with the head elevated but not positioned high enough to reach the meal tray, which was placed on the bedside table to the left side of the bed. The resident struggled to reach the tray to feed themselves. Interviews with CNAs and an LPN confirmed that the resident should have been positioned higher in the bed with the bedside table across the bed for easier access to the meal tray. The Director of Nursing also corroborated this positioning requirement. Despite these acknowledgments, the facility lacked a policy on positioning residents in bed, contributing to the observed deficiency in care for Resident #26.
Failure to Secure Indwelling Catheter with Leg Strap
Penalty
Summary
The facility failed to ensure a leg strap was in place to prevent trauma from the indwelling catheter for Resident #26, who had diagnoses of retention of urine and reflux uropathy. The resident was admitted with an indwelling catheter, and the care plan indicated that the catheter tubing should be secured to the leg with an applicable device. However, during an observation, it was noted that the indwelling catheter was not secured to Resident #26's leg with a leg strap. Both CNAs present during the observation confirmed that there was nothing to secure the tubing, and the LPN and DON also acknowledged that a leg strap or secure device should always be in place to prevent pulling or tugging of the catheter tubing. The facility did not have a policy on indwelling catheter care, and the responsibility for ensuring the leg strap was in place was stated to be shared by all staff members. The deficiency was identified through observations, interviews, and record reviews. The Admission Minimum Data Set (MDS) indicated that Resident #26 had a moderately impaired mental status and was dependent on staff for indwelling catheter care. Despite the care plan's instructions, the lack of a leg strap was observed, and staff interviews confirmed the absence of a secure device. The Director of Nursing and the Administrator both acknowledged the need for a leg strap and the shared responsibility among staff to ensure its use, but no specific policy was in place to guide this practice.
Expired Medications Found in Storage
Penalty
Summary
The facility failed to ensure expired medications were removed and placed into an area for destruction to prevent potential administration to residents. On 05/30/2024 at 1:40 PM, expired items were found in the medication storage room, including a hypodermic needle that expired on 03/31/2022, a liquid multivitamin/mineral supplement that expired in 04/2024, and 30 syringes of Lorazepam Intensol that expired on 05/04/2024. LPN #9 and LPN #10 confirmed the expiration dates and removed the items from the shelves, placing them in the medication discard box or giving them to the Director of Nursing (DON). The DON confirmed the expiration of the oral syringes.
Failure to Perform Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to perform proper hand hygiene during the care of a resident, specifically during incontinence care. Resident #9, who had diagnoses including morbid obesity, dysuria, and a urinary tract infection, was observed receiving care from a CNA. The CNA did not perform hand hygiene before applying gloves, between glove changes, or after removing gloves. This was confirmed by both the CNA and an LPN present during the care. The resident's care plan indicated a need for incontinence care due to risks related to impaired skin integrity, but the proper hand hygiene protocol was not followed during the observed care session. The Director of Nursing confirmed that hand hygiene should be performed between glove changes and after contact with soiled surfaces to prevent the spread of infection. The facility's policy on hand hygiene, which includes handwashing and the use of alcohol-based hand rubs, was not adhered to during the care of Resident #9. The policy specifies that hand hygiene should be performed before direct contact with patients, after contact with body fluids, and after removing gloves, among other situations. The failure to follow these guidelines was observed and confirmed through interviews with the involved staff and the DON.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to ensure the antibiotic stewardship program was consistently implemented, as evidenced by a resident being prescribed an antibiotic for a suspected urinary tract infection (UTI) that did not meet the selected criteria. Resident #26, who had a diagnosis of urinary retention and an indwelling catheter, was prescribed Macrobid for a UTI based on symptoms of weakness and cloudy urine. However, the resident did not exhibit other required symptoms such as fever, new flank or suprapubic pain/tenderness, change in character of urine, or worsening of mental or functional status. The APRN documented that the resident was alert, oriented, and reported no fever or abdominal pain. The urinalysis showed 1+ bacteria, but no culture and sensitivity were ordered, and the prescription was based on the appearance of the urine and the diagnosis of urinary retention, which did not meet the criteria for a UTI with a catheter as per the facility's policy. The Assistant Director of Nursing/Infection Preventionist (ADON/IP) confirmed that the antibiotic stewardship form was completed and that the criteria for prescribing antibiotics were not met. Despite this, the prescribing physician proceeded with the antibiotic prescription. The facility's Infection Prevention and Control Program policy and the Antibiotic Stewardship policy both require the use of specific criteria when considering the initiation of antibiotics. The ADON/IP documented that the urinalysis was reviewed by the medical doctor, who prescribed the antibiotic due to the urine's cloudy appearance and the diagnosis of urinary retention, which was not listed under the required criteria for a UTI with a catheter.
Failure to Perform Wound Care as Ordered
Penalty
Summary
The facility failed to perform wound care treatments as ordered by the physician for a resident with a stage 4 pressure ulcer, leading to the deterioration of the wound. The resident, who was cognitively intact, had multiple diagnoses including immunodeficiency, peripheral vascular disease, and a sacral pressure ulcer. The care plan for the resident included administering treatments as ordered and observing for effectiveness. However, the Treatment Administration Record (TAR) indicated that several wound care treatments were missed over a period of time, totaling 13 missed treatments between April and May. The resident's condition worsened, as evidenced by a Wound Healing Center Progress Note that documented the wound's deterioration. The resident was later admitted to the Intensive Care Unit with sepsis, a urinary tract infection, and a sacral decubitus ulcer. The sacral wound was noted to have a foul odor and significant undermining, with measurements indicating an increase in size compared to previous assessments. An MRI revealed osteomyelitis of the sacrum and iliac bone, with findings worse than a previous study. Interviews with facility staff, including the Director of Nursing (DON) and a Registered Nurse (RN), revealed that there was no dedicated wound care nurse, and all nurses were responsible for wound treatments. The DON confirmed that if treatments were not signed off in the TAR, they were not completed. The facility's policy emphasized the importance of following physician orders for wound care to ensure continuity of care and prevent further deterioration of pressure ulcers.
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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