The Blossoms At Cumberland Rehab & Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Little Rock, Arkansas.
- Location
- 1516 Cumberland St, Little Rock, Arkansas 72202
- CMS Provider Number
- 045359
- Inspections on file
- 38
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at The Blossoms At Cumberland Rehab & Nursing Center during CMS and state inspections, most recent first.
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.
Two residents with severe cognitive and behavioral impairments were involved in a violent altercation when one entered the other's room and was attacked with a wet floor sign, resulting in serious injuries including brain bleed, fractures, and eye trauma. Only one CNA was present on the unit, and the attack was not immediately prevented. Both residents had a history of behavioral issues, and the facility failed to provide adequate supervision and control access to potentially dangerous objects, leading to the incident.
The facility was found to have multiple deficiencies in food safety and sanitation, including the improper storage and use of dented cans, expired food items, and unsanitary conditions in the kitchen. The ice machine had residue, and dietary staff failed to follow hand hygiene protocols. Structural issues such as cracks, rust, and grease buildup were also observed, indicating a lack of maintenance.
Two residents in the facility did not receive wound care as per physician's orders, leading to deficiencies in pressure ulcer management. One resident with a stage 3 pressure ulcer and another with a stage 2 ulcer and a gastrostomy site had multiple instances of missing documentation in their Treatment Administration Records (TARs). The DON confirmed these omissions, emphasizing the importance of documenting dressing changes to monitor wound conditions. The facility's policy on wound management was not adhered to, as evidenced by the lack of documentation and care provided.
The facility did not follow the planned menu for resident meals, resulting in residents on regular, mechanical soft, and pureed diets not receiving the correct portions or types of food. Dietary staff failed to review the menu and served incorrect amounts, omitting dinner rolls and serving smaller portions than specified.
A facility failed to document a resident's advance directive in the clinical record, necessary for ensuring the resident's wishes regarding life-sustaining treatments are known. The resident, with intact cognition and multiple diagnoses, had a POLST form and Resuscitation Designation Order that did not accurately reflect their health care decision-making authority. The Power of Attorney on file did not authorize health-care decisions, and the Administrator acknowledged the need for an advance directive.
A facility failed to obtain a completed Level II PASARR evaluation for a resident with schizoaffective disorder and other mental health diagnoses. Despite approval for nursing home placement and instructions to contact the state agency for the evaluation, the administrator could not locate it. The facility also lacked a policy for handling PASARRs.
A resident, who is cognitively intact, reported not receiving showers as frequently as scheduled, with the expectation being three times per week. The facility's process involves alternating days for even and odd-numbered rooms, but documentation showed 9 instances where no bath or shower was recorded. An LPN stated that nurses do not have access to verify bathing records, and the DON confirmed the missing documentation, highlighting a deficiency in maintaining proper hygiene care.
A resident, who was cognitively intact and had multiple diagnoses, was left unsupervised with medications by both an LPN and a Medication Technician. The facility's policy required staff to observe residents taking medications to prevent harm, but this was not followed, leading to a deficiency in ensuring safety during medication administration.
A facility failed to ensure proper hand hygiene during catheter and wound care for two residents. A nurse did not perform hand hygiene between glove changes while caring for a resident with an indwelling urinary catheter and another with a gastrostomy tube and pressure ulcer. The facility lacked a formal hand hygiene policy, as confirmed by the Administrator.
A resident with multiple medical conditions did not receive physician-ordered topical ointment for dry skin on three occasions. The Treatment Nurse was unaware of the missed applications, and the Administrator reported delays in being notified about such omissions, especially when agency nurses were involved.
A resident with multiple medical conditions did not receive prescribed narcotic pain medication as ordered because the medication was not available and was awaiting delivery from the pharmacy. Staff confirmed that medication delivery delays could last one to two days, and the facility's policy required nurses to order medications and assume responsibility for delays. The administrator was often informed of these issues after they occurred, especially when agency nurses were involved.
The facility failed to complete skin treatments as ordered for three residents, leading to deficiencies in wound care management. One resident with venous ulcers missed 15 treatments, another with dry skin missed 40 days of emollient application, and a third with a deep tissue injury had 25 missed dressing changes. Observations revealed soiled and undated dressings, and residents expressed concerns about inconsistent care. The facility's minimal orientation for agency staff contributed to these issues.
The facility failed to ensure nursing staff completed treatments per physician's orders for three residents. One resident with venous ulcers had wound care treatments undocumented 15 times over three months. Another resident with pyelonephritis had emollient application undocumented for 40 days, expressing concerns about dry skin. A third resident with deep tissue damage had heel wound care undocumented 25 times. Minimal orientation for agency staff was noted, with the DON acknowledging its insufficiency.
The facility failed to maintain a clean environment, with observations of unsanitary conditions in multiple resident rooms, including dark brown buildup, sticky floors, and strong odors. The Housekeeping Supervisor admitted to the surveyor that the areas were dirty and promised to address the issue, but also revealed that the facility lacked a formal cleaning policy.
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 Prevent Resident-to-Resident Abuse Resulting in Severe Injury
Penalty
Summary
The facility failed to prevent resident-to-resident abuse involving two residents with significant cognitive and behavioral impairments. One resident, with a history of stroke, cancer, moderate cognitive impairment, and maladaptive behaviors such as inappropriate sexual behavior and wandering, was admitted to a secured unit and identified as being at risk for abnormal bleeding and skin integrity issues due to medication and medical history. The other resident, diagnosed with Alzheimer's disease, severe cognitive impairment, a history of aggression, and behavioral disturbances, was also admitted to the secured unit and had documented physical and verbal behaviors directed toward others. On the night of the incident, the resident with Alzheimer's disease physically attacked the other resident after the latter entered their room. The attack involved the use of a wet floor sign as a weapon, resulting in severe injuries including brain bleed, facial trauma, nasal bone fracture, leg fractures, and eye dislocation. Staff interviews revealed that only one CNA was present on the unit at the time, and the attack was not immediately prevented. The wet floor sign, which was typically hidden, was accessible and used in the assault. The CNA and LPN on duty responded after the incident had already occurred, and the injured resident was transported to the hospital approximately 40 minutes later. Documentation and interviews indicated that both residents had a history of behavioral issues and prior altercations, and that interventions such as one-to-one supervision and separation had been used previously. However, the facility's failure to adequately monitor and supervise these residents, as well as to control access to potentially dangerous objects, directly contributed to the occurrence of the abuse. The incident resulted in significant physical harm and psychological distress, as evidenced by the injured resident's subsequent fear of returning to the facility.
Food Safety and Sanitation Deficiencies in Facility
Penalty
Summary
The facility failed to maintain proper food safety and sanitation standards, as evidenced by several observations during the survey. Dented cans were found stored on a designated shelf in the pantry, with the Dietary Manager admitting that these cans were not removed or returned to the supplier, and were sometimes used when stock was low. Additionally, leftover meat products were improperly stored and reused for mechanical soft diets without ensuring food quality. Expired food items, such as a bag of potato chips, were not promptly removed from stock, and food items in the freezer were not properly covered or sealed. The ice machine was found to be in an unsanitary condition, with pinkish and black residue observed in the area where ice touches before dropping into the collector. The Dietary Manager confirmed the residue and stated that the ice machine was used to fill beverages for residents and was cleaned monthly. Furthermore, dietary staff failed to adhere to proper hand hygiene practices. Instances were observed where staff handled clean equipment with contaminated hands after touching dirty objects, such as removing a gallon of milk or a block of cheese from the refrigerator, without washing their hands. The kitchen environment was also found to be in poor condition, with several structural issues contributing to an unsanitary environment. Cracks in walls, broken door frames, rust stains, and grease buildup were observed in various areas, including the dishwashing machine room and around cooking equipment. These conditions indicate a lack of regular maintenance and cleaning, which are essential for ensuring a sanitary environment for food preparation and service.
Deficiency in Wound Care Documentation and Management
Penalty
Summary
The facility failed to provide wound care as per physician's orders for two residents, leading to deficiencies in pressure ulcer management. Resident #2, diagnosed with cancer, anoxic brain injury, and a stage 3 pressure ulcer, did not receive documented wound care on multiple occasions as per the Treatment Administration Records (TARs) for November and December 2024, and January 2025. The Treatment Nurse and Director of Nursing (DON) confirmed the lack of documentation, indicating that wound care was not performed as ordered, which is crucial for proper healing and infection prevention. Resident #48, with diagnoses including non-Alzheimer's dementia and hemiplegia, also experienced lapses in wound care documentation. The TARs for December 2024 and January 2025 showed missing staff initials for pressure ulcer and gastrostomy site care on several dates. The DON verified these omissions and emphasized the importance of documenting dressing changes to monitor the condition of the wounds and ensure appropriate care. The facility's policy on wound and pressure ulcer management, revised in November 2022, commits to providing comprehensive wound care consistent with residents' treatment goals. However, the lack of documentation and adherence to physician orders for wound care in these cases highlights a failure to meet these standards, as confirmed by the facility's staff during the survey.
Failure to Adhere to Planned Menu for Resident Meals
Penalty
Summary
The facility failed to ensure that meals were prepared and served according to the planned written menu, which was intended to meet the nutritional needs of the residents. During the lunch meal service, it was observed that residents on regular diets did not receive the dinner roll that was specified in the menu. Similarly, residents on mechanical soft diets were served only 2 ounces of ground turkey instead of the 3 ounces plus one ounce of gravy as outlined in the menu, and they also did not receive the dinner roll. Residents on pureed diets were served 2 ounces of pureed mixed vegetables and sweet potatoes each, instead of the specified amounts, and did not receive the pureed dinner roll as planned. Interviews with dietary staff revealed a lack of adherence to the menu. Dietary Cook #1 admitted to using a 2-ounce spoon for serving both pureed and mechanical soft meats, providing only a single serving to each resident. Dietary Cook #2 acknowledged that there was no reason for not serving the dinner rolls and admitted to not reviewing the menu before deciding on the portion sizes for the residents on mechanically soft and pureed diets. This lack of menu review and adherence resulted in the residents not receiving the appropriate portions and types of food as planned.
Failure to Document Resident's Advance Directive
Penalty
Summary
The facility failed to document a resident's advance directive in a prominent part of the clinical record, which is necessary to ensure the resident's wishes regarding life-sustaining treatments are known in the event of incapacitation. The deficiency was identified during a review of the clinical records for a resident who was admitted with multiple diagnoses, including respiratory failure and cerebral palsy. The resident's mental status was assessed as intact, with a BIMS score of 15. The Administrator provided a POLST form and a Resuscitation Designation Order for the resident, both dated prior to the survey. However, the POLST form indicated that the advance directive was not available or reviewed, and the Resuscitation Designation Order incorrectly noted that a Power of Attorney was on file for health care decisions. Upon further review, the provided Power of Attorney explicitly stated it did not authorize health-care decisions. The Administrator acknowledged that the resident would need an advance directive to indicate their preferences, as the existing documentation did not cover health care decisions.
Failure to Obtain PASARR Evaluation for Resident with Mental Disorders
Penalty
Summary
The facility failed to coordinate assessments with the PASARR program by not obtaining a completed Level II PASARR evaluation for a resident diagnosed with schizoaffective disorder, auditory hallucinations, delusional disorders, unspecified mood disorder, and anxiety disorder. The resident was admitted to the facility with a care plan initiated to address maladaptive behavioral symptoms related to chronic mental illness, including hallucinations and delusions. Despite a letter from the designated state agency approving the resident for nursing home placement and instructing the facility to contact the agency for the completed PASARR evaluation, the facility's administrator was unable to locate the evaluation. Additionally, the facility did not have a policy in place for handling PASARRs.
Failure to Adhere to Bathing Schedule for Resident
Penalty
Summary
The facility failed to ensure that a resident received a bath or shower according to the established schedule, which is essential for maintaining good hygiene. Resident #44, who is cognitively intact with a BIMS score of 15, reported that residents were not receiving showers frequently enough, with the expectation being three times per week, but only occurring once or twice. The resident requires minimal assistance but still needs staff attendance for bathing. The facility's process, as explained by an LPN, involves even-numbered rooms receiving baths on Monday, Wednesday, and Friday, and odd-numbered rooms on Tuesday, Thursday, and Saturday. However, there were gaps in the documentation, with 9 instances where no staff initials indicated that a bath or shower was completed. The LPN interviewed stated that nurses do not have access to the documentation to verify if a bath was given, and they rely on residents to inform them if they were not bathed. The Director of Nursing confirmed the missing documentation and acknowledged the importance of knowing whether a bath was completed or if there were issues preventing it. The lack of documentation and adherence to the bathing schedule led to the deficiency in providing adequate care for the resident's activities of daily living.
Failure to Supervise Medication Administration
Penalty
Summary
The facility failed to ensure safety during medication administration for Resident #44, who was cognitively intact with a BIMS score of 15 and had diagnoses including diabetes, seizure disorder, obesity, and an ulcer on the lower extremity. During an observation of the medication pass process, it was noted that both an LPN and a Medication Technician left medications with the resident without supervising their ingestion. The LPN provided two controlled substances, while the Medication Technician provided thirteen medications, both leaving the room before confirming the resident had taken the medications. Interviews with the LPN and Medication Technician revealed an acknowledgment that leaving medications unsupervised could lead to potential harm, such as the resident pocketing the medications. The facility's policy, as provided by the Administrator, explicitly stated that staff should observe residents taking their medications to prevent such risks. The Director of Nursing confirmed that the policy was in place to ensure residents did not remove pills from their mouths, highlighting a failure to adhere to established procedures designed to prevent accidents and ensure resident safety.
Inadequate Hand Hygiene During Catheter and Wound Care
Penalty
Summary
The facility failed to ensure proper hand hygiene practices during catheter and wound care for two residents. For Resident #36, who had diagnoses including coronary artery disease, neurogenic bladder, and acute kidney failure, the Treatment Nurse was observed irrigating an indwelling urinary catheter without performing hand hygiene between glove changes. The nurse acknowledged the oversight and recognized the importance of hand hygiene in preventing infection. Additionally, the facility lacked a formal hand hygiene policy, as confirmed by the Administrator. For Resident #48, who had diagnoses of non-Alzheimer's dementia, hemiplegia, and encephalopathy, the Treatment Nurse was observed changing dressings for a gastrostomy tube and a pressure ulcer without performing hand hygiene between glove changes. The nurse admitted to not consistently sanitizing hands before donning new gloves, which is crucial for reducing infection spread. The absence of a hand hygiene policy was again confirmed by the Administrator, highlighting a systemic issue in the facility's infection control practices.
Failure to Administer Physician-Ordered Skin Treatment
Penalty
Summary
Staff failed to monitor and apply physician-ordered external ointment to a resident's bilateral lower extremities for dry skin as prescribed. The resident, who had diagnoses including spinal stenosis, coronary artery disease, neurogenic bladder, and acute kidney failure, was cognitively intact according to the most recent assessment. Review of the Treatment Administration Record revealed that the ointment was not applied on three separate days as ordered. The Treatment Nurse was unaware of the missed treatments, and the Administrator acknowledged that she was often informed of such omissions after they occurred, particularly when agency nurses were involved, making timely intervention difficult.
Failure to Provide Ordered Pain Medication Due to Pharmacy Delays
Penalty
Summary
A deficiency occurred when a resident with diagnoses including spinal stenosis, coronary artery disease, and acute kidney failure did not have their ordered narcotic pain medication available for administration as prescribed. Progress notes indicated that the medication was not available on multiple occasions, with entries stating the medication was 'awaiting delivery from pharmacy' or 'pharmacy pending.' The resident was assessed as cognitively intact and was prescribed opioid medication for pain control, but the facility failed to ensure the medication was on hand for timely administration. Interviews with staff confirmed that delays in medication delivery from the pharmacy could take one to two days, and staff would call the pharmacy to request delivery. The facility's policy allowed nurses to order medications from the pharmacy and stated the facility would assume responsibility if there was a delay. The administrator acknowledged being made aware of such incidents, particularly when agency nurses were involved, and confirmed that medication was ordered as soon as possible after the issue was identified.
Failure to Complete Skin Treatments as Ordered
Penalty
Summary
The facility failed to ensure that skin treatments were completed as per physician's orders for three residents, leading to deficiencies in wound care management. Resident #2, diagnosed with venous insufficiency and chronic venous hypertension with ulcers, had a treatment plan that included washing wounds and applying collagen gel every other day. However, the Treatment Administration Record (TAR) for June, July, and August 2024 showed that treatments were not documented as completed 15 times. Resident #2 confirmed that treatments were often skipped due to nurses being busy. Resident #3, with a diagnosis of acute pyelonephritis and hydronephrosis, had an order for daily application of emollient to the lower extremities, but the TAR indicated 40 days of missed documentation. Resident #3 expressed concerns about their skin becoming dry and itchy due to inconsistent treatment. Resident #4, who had a pressure-induced deep tissue injury on the right heel, was supposed to receive daily dressing changes and offloading with a pressure-reducing boot. However, the TAR for June, July, and August 2024 documented 25 instances where the treatment was not completed. An observation revealed that Resident #4's dressing was soiled and undated. The facility's orientation for agency staff was minimal, consisting of a one-page instruction sheet, and the Director of Nursing acknowledged that the orientation was insufficient. The facility's Wound and Pressure Ulcer Management Policy required treatments to be performed according to physician orders, which was not adhered to in these cases.
Failure to Complete Physician-Ordered Treatments
Penalty
Summary
The facility failed to ensure that nursing staff completed treatments as per physician's orders for three of the four sampled residents. Resident #2, diagnosed with venous insufficiency and chronic venous hypertension with ulcers, had a physician's order for wound care that was not documented as completed 15 times over three months. Resident #3, with acute pyelonephritis and hydronephrosis, had a physician's order for applying an emollient to the lower extremities, which was not documented as completed for 40 days over the same period. Resident #3 expressed concerns about the inconsistency of treatments, noting issues with dry, flaky, and itchy skin. Resident #4, who had pressure-induced deep tissue damage and other conditions, had a physician's order for daily wound care on the right heel, which was not documented as completed 25 times over three months. The resident confirmed that treatments were frequently skipped. The facility's orientation for agency staff was minimal, consisting of a one-page instruction sheet, and the Director of Nursing acknowledged that it was not much of an orientation. The Administrator was responsible for staff scheduling, and efforts were made to maintain continuity of care by keeping the same staff with the same residents.
Facility Fails to Maintain Clean Environment
Penalty
Summary
The facility failed to maintain a clean and safe environment for its residents, as evidenced by observations made during rounds on multiple halls. A dark brown buildup with a thick black substance was noted along the baseboards and debris was found behind the doors in several resident rooms. Additionally, sticky floors were observed in some rooms, and unsanitary conditions were noted in others, including a large amount of dark brown substance in a toilet bowl, a wad of toilet tissue soaked in a yellow substance in a sink, and a used bandage on the floor. A strong odor and brown smeared areas were also found in a bathroom and on a privacy curtain. During an interview, the Housekeeping Supervisor stated that the facility performs deep cleaning on certain rooms every day according to a prepared schedule. However, the rooms that were found to be dirty were on the schedule to have already been deep cleaned, indicating a failure in the cleaning process. The Housekeeping Supervisor admitted to the surveyor that the areas were dirty and promised to address the issue. Furthermore, when asked for a cleaning policy, the Housekeeping Supervisor revealed that the facility did not have one, highlighting a lack of formal procedures to ensure cleanliness.
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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