The Blossoms At Fort Smith Rehab & Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Smith, Arkansas.
- Location
- 5301 Wheeler Avenue, Fort Smith, Arkansas 72901
- CMS Provider Number
- 045345
- Inspections on file
- 30
- Latest survey
- September 19, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at The Blossoms At Fort Smith Rehab & Nursing Center during CMS and state inspections, most recent first.
A resident with severe mental health conditions was admitted from a psychiatric facility without the required PASARR II evaluation, as the facility failed to notify the State Designated Authority and did not clarify staff responsibilities for obtaining the evaluation. Multiple staff members were unclear about the process, and necessary forms were not submitted, resulting in the evaluation only being requested after surveyor intervention.
After increasing its bed count to over 120, the facility did not hire a certified social worker as required. The current Social Services staff member lacked formal education or certification in social work, and both she and the Administrator acknowledged the need for a certified social worker based on the facility's size. There was also no policy in place for social worker staffing.
Staff did not promptly report or escalate allegations of verbal abuse involving two cognitively impaired residents, despite facility policy requiring immediate notification to the Administrator. The incidents included a CNA yelling at and using profanities toward residents, as well as rough handling of a wheelchair, with multiple staff witnessing or learning of the events but failing to ensure timely reporting and resident protection.
A resident with a history of falls and cognitive impairment collided with a laundry cart while walking to the bathroom, resulting in a head injury. The laundry technician was pushing the cart from behind, obstructing visibility. The facility's policy on resident safety was not followed, leading to the accident.
The facility failed to ensure safe wheelchair transport for a resident with multiple diagnoses, manage smoking materials properly, and maintain a clean environment in the women's secure unit shower room. A CNA let go of a resident's wheelchair, risking their safety, while another resident was found with a cigarette inside the facility, contrary to policy. The shower room had mold and clutter, and the facility lacked fitted sheets, compromising resident comfort.
The facility failed to provide toilet paper and paper towels in the women's secured unit bathrooms, affecting residents' dignity and hygiene. A resident with severe cognitive impairment and a history of trauma was directly impacted, as staff admitted to neglecting necessary perineal care. The DON and Administrator were unaware of the issue, highlighting a lapse in oversight.
A facility failed to obtain written authorization to manage a resident's personal funds, who was cognitively intact and their own POA. The resident was unaware of the management of their funds, how to access them, or the costs of services received. The Business Office Manager could not find the authorization, acknowledging the resident's decision-making capacity, leading to the deficiency.
A facility failed to provide perineal care during a brief change for a resident with severe cognitive impairment, citing a lack of paper products. Additionally, another resident received crushed iron tablets against physician orders due to a lack of liquid iron, risking potential complications. The DON was unaware of these issues, indicating a lapse in oversight and adherence to care plans.
The facility failed to ensure proper treatment and services for two residents with feeding tubes by not verifying tube placement before administering flushes and medications. An LPN was observed administering water through a PEG tube without prior placement check and used an unclean stethoscope. Interviews confirmed the importance of checking tube placement to prevent complications.
The facility failed to ensure an accident-free environment by not keeping doors locked on rooms containing chemicals and sharps. Observations revealed that doors to the hopper and shower rooms were not fully closed, exposing hazardous materials. Staff confirmed the importance of keeping these areas secure to prevent resident access. The facility's policy emphasized maintaining a hazard-free environment.
The facility failed to ensure call lights were within reach for residents, including a resident with hemiplegia, leading to potential unmet needs. Observations showed call lights were inaccessible, and staff confirmed the importance of keeping them within reach. However, the facility lacked a specific policy on call lights.
A resident with neuromuscular dysfunction of the bladder was not kept clean and dry as required, leading to soaked bedding and potential skin issues. Despite the care plan requiring checks every two hours, CNAs failed to adhere to this schedule, resulting in the resident being neglected overnight.
The facility failed to ensure proper food storage, handling, and sanitation practices, affecting 104 residents. Observations included expired milk, unsealed food items, and an ice scoop with corroded water. Staff did not consistently wash their hands before handling clean equipment or food, and cold food items were not maintained at safe temperatures. The ice machine also had wet black residue, indicating inadequate cleaning practices.
The facility failed to ensure proper hand hygiene during perineal care for a resident with severe cognitive impairment and dependency on staff for all ADLs. CNAs did not perform hand hygiene before gloving or when changing gloves, and during meal and beverage service, multiple CNAs were observed providing meals and beverages without performing hand hygiene or using gloves. The facility's policy against carrying individual sanitizer bottles and the lack of sanitizer in resident rooms contributed to the issue.
The facility failed to maintain an effective pest control program, as evidenced by multiple observations of flies in the kitchen during meal preparation. Despite pest control services targeting other pests, flies were not reported or addressed, posing a significant hygiene and health risk to 110 residents.
The facility failed to ensure the dignity and privacy of two residents who required total assistance. One resident was repeatedly observed uncovered and wearing only a brief with the door open, while another resident was exposed during perineal care due to an open door. Staff did not take immediate action to provide privacy, and the facility lacked a specific policy on perineal care.
The facility failed to ensure that pureed food items were blended to a smooth, lump-free consistency, affecting six residents on pureed diets. Observations revealed that pureed green beans, chili, sausage, and oatmeal were improperly prepared, posing a risk to residents. The deficiencies were confirmed by dietary staff.
The facility failed to protect a resident from physical abuse by another resident with known behavioral issues. The incident, which involved one resident striking another on the head, was not reported as abuse by the DON due to the absence of visible injuries and the cognitive impairment of the aggressor.
A cognitively impaired resident with a history of dysphagia was left unsupervised during meals, despite care plan requirements for supervision. Observations and staff interviews confirmed that the resident was at risk for choking and should not have been left alone.
A resident with COPD was found with an albuterol inhaler on their bedside table, despite not being assessed to self-administer medications. The facility's policy requires medications to be stored with nurses unless residents are approved for self-administration and provided with a lockbox. The DON confirmed no residents were assessed for self-administration.
Failure to Coordinate PASARR II Evaluation for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to coordinate with the State Designated Authority regarding the Pre-Admission Screening and Resident Review (PASARR) process for a resident admitted with significant mental health diagnoses, including catatonic schizophrenia, anxiety, and alcohol abuse. Upon review, it was found that the resident was admitted from a psychiatric facility and exhibited severe cognitive impairment and daily wandering behaviors. Although the State Designated Authority had provided a letter approving nursing home placement and requested to be contacted upon admission for a PASARR II evaluation, the facility did not notify the authority or request the required evaluation at the time of admission. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for obtaining the PASARR II evaluation. The MDS nurse, Social Director, Business Office Manager, and Admissions staff each believed another department was responsible for securing the evaluation, and no related policies or procedures were in place. The forms required for the process were completed but not submitted, and the State Designated Authority was only contacted after the surveyor's inquiry, confirming that the resident was indeed a PASARR II case.
Failure to Employ Qualified Social Worker After Bed Count Increase
Penalty
Summary
The facility failed to employ a qualified, certified social worker after its bed count exceeded 120, as required by regulations. Interviews with the Administrator confirmed that the facility had 130 beds and had surpassed the 120-bed threshold since July 2024, but did not have a certified social worker on staff. The current Social Services staff member, who had been employed for two and a half years, lacked formal education or certification in social work and believed she could work under the Administrator's degree in social work. Both the Administrator and the Social Services staff member acknowledged the requirement for a certified social worker given the facility's size, and the Administrator further indicated that there was no policy in place for staffing a social worker.
Failure to Timely Report and Respond to Allegations of Verbal Abuse
Penalty
Summary
Staff failed to report allegations of verbal abuse involving two residents to the Administrator within two hours, as required by facility policy. The incidents involved a CNA who was observed yelling at and using profanities toward residents, as well as physically handling a resident's wheelchair in a rough manner. Multiple staff members, including LPNs, witnessed or were made aware of these actions but did not immediately report the allegations to the Administrator. Instead, the incidents were either reported several hours later or not at all until prompted by further inquiry. The residents involved had significant cognitive impairments and histories of trauma, with one being a hospice patient and the other requiring assistance for daily care and residing on a secure unit. During the night shift, the CNA was observed yelling at one resident in the shower, causing the resident to cry, and was also reported to have spoken harshly and handled another resident's wheelchair roughly, resulting in distress. Staff interviews confirmed that the CNA's actions were loud enough to be heard through closed doors and that the residents were visibly upset by the interactions. Despite facility policy and repeated abuse prevention training, staff did not follow the required protocol for immediate reporting. LPNs and other staff either delayed reporting or failed to escalate the incidents to the Administrator as mandated. The failure to promptly report and respond to the allegations resulted in a lack of immediate protection for the residents involved, as the alleged perpetrator was not removed from contact with residents until after the incidents had occurred.
Failure in Safe Laundry Transport Leads to Resident Injury
Penalty
Summary
The facility failed to ensure safe laundry transport techniques, resulting in an accident involving a resident. The resident, who had a history of falls and was at risk for abnormal bleeding due to antiplatelet therapy, collided with a laundry cart while walking to the bathroom. The resident had moderate cognitive impairment and was diagnosed with conditions such as generalized anxiety disorder, psychosis, schizophrenia, and lack of coordination. During the incident, the resident ran into the cart and fell backward, sustaining a head injury that required emergency room evaluation. The incident occurred when a laundry technician was pushing a tall laundry cart from behind, making it difficult to see residents in the path. The laundry technician and the Housekeeping & Laundry Supervisor both acknowledged that the proper technique should involve standing in front of the cart to ensure visibility of any residents. The facility's policy on resident rights emphasizes the right to a safe environment, which was not upheld in this instance, leading to the resident's injury.
Deficiencies in Resident Safety, Smoking Policy, and Facility Cleanliness
Penalty
Summary
The facility failed to ensure safe wheelchair transport techniques for a resident with multiple diagnoses, including Parkinson's disease, dementia, and PTSD. During an observation, a CNA was seen pushing the resident in a wheelchair and then letting go of the handles, causing the wheelchair to move forward without control. This action risked the resident's safety, as the wheelchair nearly collided with a door frame. The resident's care plan highlighted the need for trauma-informed care and monitoring for safety due to their conditions and medication use, which increase the risk of falls and confusion. The CNA admitted to being preoccupied and in a rush, which led to the lapse in safety protocol. The facility also failed to properly manage smoking materials, as a resident was observed with a cigarette in their mouth inside the facility, contrary to the smoking policy. The policy mandates that all smoking materials be kept in a secure location and that residents should not have access to them. The resident, who has moderate cognitive impairment, was not identified as a current tobacco user in their care plan, and staff were unaware of how the resident obtained the cigarette. The DON and Administrator acknowledged the issue but were uncertain about the procedure for storing cigarettes between smoke breaks. Additionally, the facility did not maintain a clean and sanitary environment in the women's secure unit shower room, which was found to have standing water, mold, rust, and clutter. Housekeeping staff were assigned to clean the area daily, but the issues were not reported or addressed. The maintenance department was also found to be lacking in communication and follow-up on repairs, as evidenced by broken tiles in a resident's room that had not been fixed. Furthermore, the facility was short on fitted sheets, leading to residents using flat sheets and blankets on their beds, which compromised their comfort and hygiene.
Failure to Provide Toilet Paper and Towels in Women's Unit
Penalty
Summary
The facility failed to maintain the dignity of residents by not providing toilet paper and paper towels in the bathrooms of the women's secured unit. This deficiency was observed during a survey when it was noted that neither of the two bathrooms on the unit had these essential hygiene products available. The absence of these items was confirmed by a Certified Nursing Assistant (CNA) who stated that the decision was made to prevent toilets from clogging due to excessive use of paper products by residents. This lack of provision directly affected Resident #10, who has severe cognitive impairment and requires assistance with toileting and hygiene, as well as other residents on the unit. Resident #10, who has a history of trauma and requires trauma-informed care, was observed entering a bathroom without toilet paper or paper towels available. The CNA assisting Resident #10 admitted to forgetting to perform perineal care, which is crucial to prevent infections and maintain cleanliness. The Director of Nursing (DON) and the Administrator were both unaware of the situation until it was brought to their attention, indicating a lapse in oversight and communication within the facility. The deficiency potentially affected all 24 residents residing on the women's secured unit, compromising their right to a dignified existence and proper hygiene care.
Failure to Obtain Authorization for Managing Resident's Personal Funds
Penalty
Summary
The facility failed to honor a resident's right to manage their own financial affairs, as evidenced by the lack of written authorization to manage personal funds for a resident who was cognitively intact and their own Power of Attorney. The resident, admitted with diagnoses including injury at the C7 level of the cervical spine, functional quadriplegia, depression, and panic disorder, was unaware of whether the facility was managing their money, how to access their funds, or the costs of services received, such as haircuts. The resident believed they were entitled to a monthly allowance but had not received any money or account information. Interviews revealed that the Business Office Manager was unable to locate an authorization for managing the resident's funds and acknowledged that the resident was their own decision-maker. The resident's lack of awareness regarding their financial management and the facility's failure to provide necessary information and authorization contributed to the deficiency. The issue was identified during a survey, highlighting the facility's failure to ensure the resident was informed and had control over their personal funds.
Failure in Perineal Care and Medication Administration
Penalty
Summary
The facility failed to provide adequate perineal care during a soiled brief change for a resident with severe cognitive impairment and a history of trauma. The resident required extensive assistance with toileting, including perineal care every two hours and as needed. During an observation, a CNA changed the resident's brief without performing perineal care, citing a lack of available paper products in the bathroom as the reason. The CNA acknowledged the oversight, and the Director of Nursing was unaware of the decision to remove paper products from the bathroom, which was intended to prevent clogs. Additionally, the facility did not follow physician orders for medication administration for another resident with severe cognitive impairment and a feeding tube. The resident was prescribed an iron tablet that should not be crushed, but due to a lack of liquid iron, the LPN had been crushing the tablets for administration. The DON confirmed that the iron tablets were enteric-coated and should not be crushed, as this could lead to potential complications. These deficiencies highlight a failure in adhering to care plans and physician orders, as well as a lack of communication and oversight regarding the availability of necessary supplies and the proper administration of medications.
Failure to Verify Tube Placement Before Administration
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent complications from enteral feedings for two residents who were reviewed for tube feeding. Specifically, the facility did not appropriately check tube placement prior to administering flushes and/or medications for these residents. Resident #7, who has a diagnosis of metachromatic leukodystrophy, gastrostomy status, and dysphagia, was admitted to the facility in 2015 and requires a feeding tube for nutrition and fluids. Resident #9, diagnosed with Huntington Disease, gastrostomy status, and dysphagia, was admitted in 2014 and is in a vegetative state, requiring all nutrition and fluids through a feeding tube. The facility's policy mandates checking enteral tube placement prior to each feeding and administration of medication, which was not adhered to in these cases. Observations revealed that an LPN administered water through a PEG tube to Resident #9 without checking placement beforehand and used an unclean stethoscope to check for air movement in the stomach. The LPN also failed to aspirate gastric residual for placement verification and improperly handled a clogged PEG tube. Interviews with facility staff, including an RN and the Director of Nursing, confirmed the importance of checking PEG tube placement prior to medication administration or feedings to ensure the tube is correctly positioned in the stomach. The facility's failure to follow its policy and procedures for checking tube placement led to the identified deficiencies.
Failure to Secure Hazardous Areas
Penalty
Summary
The facility failed to maintain an accident and hazard-free environment by not ensuring that doors to rooms containing chemicals and sharps were locked. On the morning of September 18, 2024, it was observed that the hopper room door on the 300 Hall was not completely closed, allowing access to chemicals and overflowing sharps containers. The room also had a foul odor and a brown substance covering the inside of the hopper. Similarly, the shower room door on the Administration Hall was not fully closed, exposing chemicals such as rinse-free body wash, deodorant, anti-perspirant, shaving cream, body oil, and skin protectant, some of which had warnings about ingestion risks. Interviews with staff confirmed that these doors should always be closed and locked to prevent resident access to hazardous materials. A CNA acknowledged the potential for injury if residents accessed chemicals or sharps, while an LPN confirmed that sharps containers should not be overflowing and should be securely stored until picked up by a medical waste company. The facility's policy on Accidents and Hazards, provided by the Administrator, indicated a commitment to maintaining a hazard-free environment, and in-services had been conducted earlier in the year to reinforce the importance of keeping doors with locks shut completely.
Failure to Ensure Call Lights Within Reach
Penalty
Summary
The facility failed to ensure that residents had reasonable accommodation of needs by not keeping call lights within reach for residents. Specifically, Resident #6, who had a diagnosis of hemiplegia and used a wheelchair, was observed on multiple occasions with the call light out of reach. On 9/17/2024, the call light was behind the chair the resident was sitting in, and on 9/18/2024, it was under the wheel of the bedside table, both times inaccessible to the resident. Additionally, another resident, Resident #15, was observed with the call light on the floor, out of reach. Interviews with CNAs and an LPN confirmed that staff were aware that call lights should be within reach before leaving a resident's room to ensure residents can call for assistance if needed. Despite this understanding, the facility did not have a specific policy related to call lights, and an in-service issued earlier in the year was not effectively implemented.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of neuromuscular dysfunction of the bladder was kept clean and dry, as required for their care. The resident, who had moderate cognitive impairment and occasional urinary incontinence, was observed with a soaked brief, pad, and sheet. The care plan for the resident indicated that they required extensive assistance with toileting and incontinence care every two hours and as needed. However, it was noted that the resident had not been checked on throughout the night, leading to the observed condition. Certified Nurse Aide (CNA) #5 reported changing the resident at the beginning of their shift, which started at 11:00 PM, and again at approximately 12:00 AM. Despite this, the resident was found in a state of neglect by 5:37 AM, indicating a lapse in the required two-hour checks. CNA #4, who was responsible for checking the resident during the morning, admitted it was her first time checking on the resident during her shift and was unsure if CNA #5 had checked on the resident during the night. This lack of adherence to the care plan resulted in the resident's skin being red on the lower abdomen and inner thighs, indicating potential skin breakdown due to prolonged exposure to moisture.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure proper food storage, handling, and sanitation practices in the kitchen, which had the potential to affect 104 residents. Observations included expired milk in the refrigerator, an opened and unsealed box of French toast in the freezer, and an ice scoop with brown/black corroded water. Additionally, staff did not consistently wash their hands before handling clean equipment or food items, as evidenced by multiple instances where dietary staff touched dirty objects and then handled clean equipment or food without washing their hands. Furthermore, cold food items were not maintained at or below 41 degrees Fahrenheit, with temperatures recorded as high as 60 degrees Fahrenheit for certain items. The ice machine also had wet black residue on the inside top panel, indicating inadequate cleaning practices. The facility's policy on hand washing was not followed, as staff failed to wash their hands at the start of their shift, before donning disposable gloves, and after engaging in activities that contaminated their hands. Specific instances included a dietary cook handling a can of peach halves and a clean blender blade without washing her hands, and another dietary aide touching his beard cover and then handling a clean blade without washing his hands. Additionally, the temperature of pureed cornbread with milk was recorded at 112 degrees Fahrenheit and was not reheated before being served to residents. These deficiencies indicate a lack of adherence to professional standards for food storage, preparation, and sanitation, potentially compromising the safety and well-being of the residents.
Failure to Ensure Proper Hand Hygiene During Perineal Care and Meal Service
Penalty
Summary
The facility failed to ensure proper hand hygiene was performed during perineal care for a resident with severe cognitive impairment and dependency on staff for all activities of daily living. During an observation, two CNAs entered the resident's room to perform a brief change and provide perineal care without performing hand hygiene before gloving or when changing gloves. The CNAs also did not perform hand hygiene or change gloves when moving from dirty to clean tasks. The CNAs expressed concerns about the lack of sanitizer in the rooms and the facility's policy against carrying individual sanitizer bottles in their pockets, which would require them to leave the resident unattended to access sanitizer in the hallway. During meal and beverage service, multiple CNAs were observed providing meals and beverages without performing hand hygiene or using gloves. One CNA spilled tea and sugar on the beverage cart and used a spoon to stir the drinks, placing the spoon back on the cart in the spilled fluids. The CNA did not clean the cart or perform hand hygiene during the beverage pass. Other CNAs were observed opening milk cartons with ungloved hands, touching the area where residents place their mouths to drink. Interviews with the CNAs revealed that they were aware of the need for hand hygiene but did not consistently practice it during meal and beverage service. The Director of Nursing and a Registered Nurse acknowledged the issues with hand hygiene and stated that in-services were started to address the problem. However, the facility's policy of not allowing small bottles of sanitizer due to cross-contamination concerns and the lack of sanitizer in resident rooms contributed to the failure to perform proper hand hygiene. The DON stated that staff would be taking in a medication cup of hand sanitizer to use in the room and must wrap it in a glove to dispose of it, so residents do not have access to it.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple observations of flies in the kitchen during meal preparation. On 05/22/24, flies were observed on a food preparation counter, a spoon, a bread bag, a utility food cart, and the steam table bar. The Dietary Supervisor acknowledged the issue, attributing it to changing weather conditions and mentioned that some utensils had been washed the previous day. However, the presence of flies persisted, indicating an ongoing problem. Further review of pest control service reports from 03/15/24, 04/04/24, and 05/17/24 revealed that while other pests such as rodents, roaches, ants, beetles, crickets, spiders, and wasps were targeted and treated, flies were not reported or addressed. This oversight in the pest control program had the potential to affect 110 residents, as the presence of flies in food preparation areas poses a significant hygiene and health risk.
Failure to Ensure Resident Privacy and Dignity
Penalty
Summary
The facility failed to ensure the dignity and privacy of two residents who required total assistance. Resident #7, diagnosed with Cerebral Palsy and Calorie Malnutrition, was observed lying in bed uncovered and wearing only a brief on multiple occasions. The resident's door was open to the hallway, and the privacy curtain was not pulled closed. Despite several staff members, including CNAs and a nurse consultant, observing the resident in this state, no immediate action was taken to cover the resident or close the privacy curtain. The Director of Nurses (DON) mentioned that the resident was care planned to not use covers and was scared to have the curtain pulled, but this preference was not documented in the resident's care plan. Resident #88, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was observed receiving perineal care with the door left open, exposing the resident to the hallway. CNA #10 entered the room without closing the door, leaving the resident without privacy. CNA #8 acknowledged the lack of privacy and subsequently closed the door. The DON confirmed that the facility did not have a specific policy on perineal care, and RN #12 stated that staff should provide privacy by closing shades, pulling curtains, and closing doors when providing care that exposes a resident.
Improper Preparation of Pureed Food Items
Penalty
Summary
The facility failed to ensure that pureed food items were blended to a smooth, lump-free consistency, which is essential to minimize the risk of choking or other complications for residents requiring pureed diets. During observations, it was noted that the pureed green beans and chili prepared by Dietary Cook #14 were thin and not properly formed. Additionally, during a breakfast meal observation, the pureed sausage was found to be gritty, and the pureed oatmeal was thin and not properly formed. These deficiencies were confirmed by the Dietary Supervisor and Dietary Cook #16, who acknowledged the improper consistency of the pureed food items served to the residents. The failed practice had the potential to affect six residents who required pureed diets. The observations and interviews revealed that the dietary staff did not consistently achieve the required smooth, lump-free consistency for pureed foods, which is critical for the safety and well-being of residents on such diets. The dietary staff's inability to properly prepare pureed foods was evident in multiple instances, including lunch and breakfast meals, where the food items did not meet the necessary standards for texture and consistency.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect Resident #83 from physical abuse by another resident, Resident #19, who had known behavioral issues. Resident #83, who was moderately cognitively impaired and used a wheelchair, was struck on the back of the head by Resident #19 in the dining room. This incident caused Resident #83 to lift out of their wheelchair. Despite the severity of the incident, the Director of Nursing (DON) did not consider it abuse because there were no visible injuries, and thus, it was not reported as such. Resident #19 had a history of aggressive behaviors, including hitting, kicking, and pushing others, as documented in their care plan. The resident had severe cognitive impairment and exhibited physical behavioral symptoms directed toward others. On the day of the incident, Resident #19 was noted to have a change in condition related to behavioral symptoms and was placed on one-on-one observation after the altercation. The DON and Administrator were questioned about the incident and their decision not to report it as abuse. The DON argued that the lack of visible injuries and the cognitive impairment of Resident #19 meant the incident did not qualify as abuse. The DON also mentioned that similar minor physical interactions between residents occur frequently and are not reported. This stance was maintained despite documentation indicating that Resident #19's actions had a significant physical impact on Resident #83.
Failure to Supervise Cognitively Impaired Resident During Meals
Penalty
Summary
The facility failed to ensure adequate supervision for a cognitively impaired resident at risk for choking during in-room meal service. Resident #91, who has severe cognitive impairment and a history of dysphagia, was observed eating alone in their room on multiple occasions. Despite having a care plan that required supervision during meals, staff did not remain with the resident, leaving them unsupervised while eating. This lack of supervision was observed on two separate occasions, where the resident was seen eating alone and engaging in potentially unsafe behaviors such as standing up and using utensils improperly. The resident's medical history includes early onset Alzheimer's Disease, dementia, and a need for assistance with personal care. The resident's care plan and speech therapy evaluation indicated the need for close supervision during meals due to swallowing difficulties. However, observations revealed that staff did not adhere to these requirements, as the resident was left alone during meal times. Interviews with staff, including CNAs and the Director of Nursing, confirmed that the resident should not be left unsupervised due to the risk of choking. The Speech Language Pathologist (SLP) had evaluated the resident and recommended supervision during meals to ensure safe swallowing. Despite these recommendations, the resident was left alone, and staff were unaware of the need for supervision. This failure to provide adequate supervision during meals for a resident with known swallowing difficulties constitutes a significant deficiency in the facility's care practices.
Failure to Ensure Proper Medication Storage for Resident
Penalty
Summary
The facility failed to ensure prescribed medications remained with the nurse for a resident who was not assessed to self-administer medications. The facility's policy, dated 12/26/2022, stated that medications should not be stored in a resident's room unless the resident has been approved for self-administration and provided with a lockbox. Resident #31, who was admitted with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD), was observed with an albuterol inhaler on their bedside table on two separate occasions. The resident had a Brief Interview of Mental Status (BIMS) score of 12, indicating cognitive intactness, but was not assessed or care planned to self-administer medications. During an interview, RN #19 confirmed the presence of the albuterol inhaler on Resident #31's bedside table and acknowledged the importance of assessing residents for self-administration to prevent medication misuse. The Director of Nursing (DON) later confirmed that no residents in the facility, including Resident #31, were assessed to self-administer medications. The DON emphasized the importance of keeping medications with the nurses for the safety of the residents.
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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