Trinity Village Medical Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pine Bluff, Arkansas.
- Location
- 6400 Trinity Drive, Pine Bluff, Arkansas 71603
- CMS Provider Number
- 045438
- Inspections on file
- 33
- Latest survey
- July 24, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Trinity Village Medical Center during CMS and state inspections, most recent first.
A facility failed to protect residents' personal and medical information, violating HIPAA. LPNs left laptops open and unlocked on medication carts, displaying sensitive information. The Director of Nursing confirmed that nurses should secure computer screens to prevent unauthorized access, as per facility policy.
The facility failed to update care plans for two residents, one with a history of falls and another on antipsychotic medication. Despite a fall and increased fall risk for one resident, the care plan was not revised with new interventions. For the other resident, the care plan did not correctly document the antipsychotic medication or include monitoring for adverse reactions. The MDS Coordinator acknowledged these oversights.
The facility failed to properly assess and document the use of bed rails for two residents, leading to deficiencies in care. One resident, with a history of epilepsy, had side rails in use without a documented assessment or physician order, despite a care plan indicating they should remain down. Another resident, dependent on staff for mobility, was observed with bed rails up without a physician order or risk assessment. Staff interviews revealed inconsistencies in the initiation and monitoring of bed rail use.
The facility's medication error rate exceeded 5%, with errors involving two residents. One resident received an incorrect dose of a calcium channel blocker due to a pharmacy change, while another had an NSAID applied inconsistently with the prescribed order. Both residents were cognitively intact, and the errors were attributed to deviations from the facility's medication administration policy.
A facility failed to prevent significant medication errors for two residents. One resident received an incorrect dose of a calcium channel blocker for a month due to a pharmacy change, while another resident was given long-acting insulin past its 28-day usage period. The errors were confirmed by LPNs and acknowledged by the DON, indicating a lapse in adherence to medication administration policies.
The facility failed to secure medication carts, leaving them unlocked and unattended, which could allow unauthorized access to medications. Additionally, a resident's insulin was used beyond the recommended 28-day period, with staff unsure of the correct usage dates. The DON confirmed the need for secure storage and proper disposal protocols.
The facility failed to follow the planned menu for resident meals, resulting in residents receiving less food than required. Dietary staff served only one slice of pizza instead of two to residents on regular, mechanical soft, and chopped diets. Additionally, residents on pureed diets received only one scoop of pureed pizza instead of two. The staff did not adhere to menu guidelines, leading to incorrect portion sizes being served.
The facility failed to maintain proper food safety and sanitation standards, with uncovered and improperly stored food items, inadequate hand hygiene by dietary staff, and a poorly maintained kitchen environment. Observations included contaminated gloves used for food handling, stained ceiling tiles, and food items served at incorrect temperatures. The facility's policies on leftovers and handwashing were not followed.
A facility failed to ensure enhanced barrier precautions (EBP) were followed for a resident with multiple diagnoses, including Alzheimer's disease. Despite EBP signage and PPE availability, staff were observed providing care without PPE. The facility's policy requires PPE during high-contact activities, but some staff did not adhere to these precautions, leading to the deficiency.
A facility failed to implement a care-planned positioning device for a resident with a CVA to prevent further contracture. Despite the care plan's intervention to place a carrot in the resident's hand, observations revealed no device in place. An LPN mentioned Hospice's instruction to discontinue the carrot due to a past fracture, but no documentation was provided. The DON's review of the Hospice care plan showed no contracture addressal, and the facility's ROM policy lacked relevant information.
A facility failed to attempt gradual dose reductions for a resident on anti-anxiety medication without a physician's documented evaluation of risks versus benefits. The resident, cognitively intact, was on a PRN benzodiazepine without documentation of dose reduction attempts or justification. The DON acknowledged the deficiency, and the facility's policy on Drug Regimen Review was not adequately followed.
The facility failed to ensure pureed food items were blended to a smooth consistency for residents on pureed diets. A dietary staff member, DC #7, prepared pureed squash that remained runny and pureed pizza that contained pieces, indicating insufficient blending. The staff member acknowledged the issues during an interview.
The facility failed to maintain sanitary conditions in the kitchen and food storage areas, affecting 75 residents. Observations included dirty trash cans near food prep areas, ice buildup in the freezer, and improper storage of opened food items. The ice machine and scoop were unsanitary, and dietary staff did not follow hand hygiene protocols, handling food and equipment without washing hands. Hot food items were not kept at required temperatures, and the facility's hand washing policy was not adhered to.
The facility did not refund the remaining funds of two deceased residents to their families within the required 30 days. The Business Office confirmed a process failure, as the balances remained in the residents' accounts without charges. The facility's policy mandates timely conveyance of funds, which was not followed.
The facility failed to secure the G Hall shower room and beauty shop, leaving hazardous chemicals accessible to residents. Uncapped shampoo and personal cleanser were found in the shower room, while the beauty shop contained unlocked disinfectant spray and hairspray. Additionally, an open closet and unattended office housed harmful chemicals. Staff confirmed the lack of security measures and acknowledged the potential risk to residents.
Two residents with COPD and other respiratory conditions were not administered oxygen at the physician-ordered rate, receiving less than prescribed. This was confirmed by staff, including an LPN and the DON, who acknowledged the discrepancies and the responsibility of nurses to ensure correct oxygen settings.
A resident with severe cognitive impairment and atrial fibrillation was not properly monitored for adverse effects of anticoagulant medication, leading to unaddressed bruising. Staff, including LPNs and CNAs, were not adequately trained to access care plans or monitor high-risk medications, resulting in a failure to conduct necessary skin audits and document observations. The facility lacked documentation of training for aides on monitoring residents on high-risk medications.
The facility failed to conduct monthly Medication Regimen Reviews (MRR) for several residents, as required. A resident with severe cognitive impairment and significant medical diagnoses lacked documented MRRs for multiple months. Another resident, cognitively intact and on multiple medications, also had missing MRR documentation. A third resident, moderately cognitively impaired, had incomplete care planning and missing MRRs. The DON acknowledged the absence of these records, indicating a systemic issue in maintaining accurate medication review records.
The facility failed to securely store medications, with unlocked medication carts and medications left at the bedside for two residents. An oxygen concentrator propped open a door to a room with unsecured medications. Additionally, narcotic medications were not stored in permanently affixed compartments. The DON confirmed that no residents had self-administration rights and that families were instructed not to bring medications into the facility.
The facility failed to prepare and serve meals according to the planned menu for residents on pureed and mechanical soft diets. The dietary staff did not prepare or serve the required gravy and mashed potatoes, affecting 11 residents on pureed diets and 6 on mechanical soft diets. The staff admitted to rushing and overlooking these items, leading to insufficient servings and portions.
The facility failed to provide pureed food items with the required smooth consistency for residents on pureed diets. Observations revealed that pureed polish sausage, cornbread, and cabbage were not properly blended, resulting in lumpy, gritty, and runny textures. Staff interviews confirmed these deficiencies, affecting the dietary needs of 11 residents.
The facility did not follow the physician's orders for chopped meat diets for eight residents. During meal preparation, kielbasa was not pre-chopped, and three residents were served Polish sausage pieces that were too large, contrary to the prescribed diet. The Dietary Manager confirmed the non-compliance with the diet requirements, which were meant to ensure the food was soft, bite-sized, and easy to chew.
The facility did not ensure that the Binding Arbitration Agreement informed residents or their representatives that signing was not required for admission or continued care. The agreement lacked necessary wording, and a social worker confirmed families were verbally informed of their rights, but this was not documented.
The facility failed to implement a water management program to prevent Legionella growth, lacked enhanced barrier precautions for a resident with a PEG tube, and did not ensure proper hand hygiene and storage practices. Staff were not adequately trained on infection control measures, leading to potential cross-contamination and infection risks.
A resident with a hand contracture was not consistently provided with a prescribed palm guard, despite having a physician's order for its use during the day. Observations revealed the resident without the device on multiple occasions, and staff interviews indicated confusion over responsibility for its application. The facility's policy aimed to maintain or improve residents' abilities, yet the palm guard was not applied as required.
A resident with chronic kidney disease, dementia, and metabolic encephalopathy did not receive adequate dental care, as observed by surveyors. The resident required assistance with oral hygiene, but staff failed to provide necessary care, resulting in noticeable dental issues. The DON confirmed staff responsibilities for dental care, but the facility's policies were not followed, leading to this deficiency.
A resident with hemiplegia, hemiparesis, and dementia did not receive proper incontinent care, as observed by surveyors. Two CNAs failed to use the correct technique and adequate supplies, which was confirmed by the CNAs and the DON. This failure to adhere to the facility's perineal care policy posed a potential risk of infection.
HIPAA Violation Due to Unsecured Laptops
Penalty
Summary
The facility failed to protect the personal and medical information of three residents, potentially violating the Health Insurance Portability and Accountability Act (HIPAA). The incidents involved Licensed Practical Nurses (LPNs) leaving laptops open and unlocked on medication carts in the hallway, displaying residents' personal and medical information such as names, dates of birth, code statuses, and physician's orders. These actions were observed by a surveyor during medication administration rounds. In one instance, an LPN left the laptop open while retrieving oxygen tubing, and in another, an LPN left the laptop open while getting over-the-counter medication. The Director of Nursing acknowledged that the nurses should lock or close the computer screens before walking away to prevent unauthorized access to residents' personal and medical information. The facility's policy on HIPAA Basics for Providers emphasizes the need to secure patient records containing Protected Health Information (PHI) to prevent access by unauthorized individuals. The failure to adhere to this policy resulted in the exposure of sensitive information for three residents, including one with moderately impaired cognition and another who was cognitively intact.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to ensure care plans were revised to reflect the most recent care needs of two residents. Resident #24, who had a history of diabetes mellitus with foot ulcer, adjustment disorder with depressed mood, and myocardial infarction, experienced a fall on 12/13/2024. Despite a progress note by the nurse practitioner indicating increased fall frequency and a fall risk assessment confirming the resident's risk, the care plan was not updated with new interventions after the fall. The MDS Coordinator stated that care plans were updated as necessary and at least quarterly, but the care plan for Resident #24 did not reflect the necessary changes following the incident. Resident #45, diagnosed with depression, was prescribed an antipsychotic medication, which was not correctly documented in the care plan. The care plan failed to indicate that the medication was an antipsychotic and did not include monitoring for adverse reactions. The MDS Coordinator acknowledged the oversight, stating that the medication should have been documented under antipsychotic medications and that monitoring for adverse reactions should have been included. The facility's policy required care plan interventions to be derived from a thorough analysis of comprehensive assessment data, but this was not adhered to in these cases.
Deficiency in Bed Rail Use and Assessment
Penalty
Summary
The facility failed to ensure the proper use of bed rails for two residents, leading to deficiencies in their care. Resident #28, who had diagnoses of gastrostomy and a pressure ulcer, was observed with bed rails up despite no physician order for their use. The resident was totally dependent on staff for mobility and had not experienced falls, yet the care plan indicated the use of side rails for positioning. Staff interviews revealed a lack of clarity on when the bed rails were initiated and highlighted the absence of a risk versus benefit assessment or responsible party notification in the electronic health record. Similarly, Resident #1, diagnosed with symptomatic epilepsy, was found with side rails in use without a documented assessment or physician order. The care plan indicated a request for assist rails to remain down, yet staff interviews confirmed the use of side rails for turning and repositioning. The Assistant Director of Nursing acknowledged the need for care planning and documentation of side rail use, but no assessment was provided before the survey exit. These actions and inactions demonstrate a failure to adhere to facility policy and regulatory requirements for bed rail use.
Medication Error Rate Exceeds 5% Due to Incorrect Dosing and Application
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with the observed rate being 7.14%. This deficiency was identified through observations, interviews, and record reviews involving two residents. Resident #44, who was cognitively intact with a BIMS score of 15, had a care plan addressing hypertension and hyperlipidemia. The resident was prescribed a calcium channel blocker at 90 mg daily, but was incorrectly administered only 30 mg by LPN #1 due to a pharmacy change. The Director of Nursing acknowledged the error, emphasizing the facility's responsibility to ensure accurate medication dosing. Another incident involved Resident #1, also cognitively intact with a BIMS score of 15, who had arthritis and was at risk for pain. The resident's care plan included the application of an NSAID to specific areas every four hours. However, LPN #6 applied the medication inconsistently with the prescribed order, applying it to the right leg, knee, and foot, and only to the left foot, based on the resident's preference rather than the prescribed method. The facility's policy required medications to be administered as prescribed, with verification of the right resident, medication, dose, time, and route, which was not adhered to in these cases.
Medication Errors in Dosage and Expiry in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by two separate incidents involving medication administration. In the first incident, a resident with a history of hypertension and hyperlipidemia was administered an incorrect dose of a calcium channel blocker medication for the entire month of January 2025. The resident was supposed to receive 90 mg of the medication daily, but was instead given only 30 mg due to a pharmacy change that resulted in the wrong dosage being supplied. This error was observed by a surveyor and confirmed by an LPN, who acknowledged that the resident was not receiving the prescribed amount of medication. The Director of Nursing admitted that the facility was responsible for ensuring the correct dosage was administered, despite the pharmacy change. In the second incident, another resident with type 2 diabetes mellitus was administered long-acting insulin past its recommended usage period. The insulin vial had conflicting dates, and the LPN responsible for administering the medication was unsure of the correct date the vial was accessed. The insulin was used beyond the 28-day period recommended by the FDA, as confirmed by the LPN after reviewing the calendar. The Director of Nursing stated that it was the nurses' responsibility to check the dates on insulin vials to ensure they were used within the appropriate timeframe. These incidents highlight the facility's failure to adhere to medication administration policies, resulting in significant medication errors for the residents involved.
Medication Storage and Insulin Disposal Deficiencies
Penalty
Summary
The facility failed to ensure the secure storage of medications and biologics, as observed during a survey. On multiple occasions, LPNs were seen leaving medication carts unlocked and unattended while administering medications to residents. This lapse in protocol was acknowledged by the LPNs, who admitted to not locking the carts, thereby potentially allowing unauthorized access to medications, including controlled substances. The Director of Nursing confirmed that medication carts should be locked when unattended to prevent unauthorized access. Additionally, the facility did not adhere to the proper disposal protocol for insulin. A vial of long-acting insulin for a resident with type 2 diabetes mellitus was found to have been in use beyond the recommended 28-day period. The LPN responsible for the insulin was uncertain about the correct date of first use and acknowledged that the insulin should have been disposed of and reordered after 28 days. The Director of Nursing confirmed that it is the nurses' responsibility to check the dates on insulin vials to ensure they are used within the appropriate timeframe.
Failure to Follow Menu Guidelines for Resident Meals
Penalty
Summary
The facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents. During the lunch meal preparation, dietary staff did not follow the menu instructions for serving pizza to residents on different diets. Specifically, residents on regular, mechanical soft, and chopped diets were supposed to receive two slices of pizza each, but they were only given one slice. Additionally, residents on pureed diets were supposed to receive two #8 scoops of pureed pizza, but they were only given one scoop. The dietary staff, DC #10 and DC #9, did not adhere to the menu guidelines, resulting in residents receiving less food than required. The dietary staff's actions were based on instructions from the Dietary Manager, who directed them to serve only one slice of pizza per resident. Furthermore, DC #9 did not review the menu before serving the pureed pizza, leading to incorrect portion sizes being served. The staff also used incorrect scoop sizes for serving, with DC #9 using a #10 scoop instead of the required #8 scoop for pureed diets. These actions resulted in the residents not receiving the appropriate amount of food as per their dietary needs, as outlined in the facility's menu.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain proper food safety and sanitation standards in several areas of its kitchen and food storage facilities. Observations revealed that food items in the refrigerator, freezer, and storage room were not properly covered or sealed, including bags of pizza, apple pie, shredded cheese, and leftover spaghetti. Additionally, dented cans were found in the storage room, and an ice machine was discovered to have a black and brown slimy residue, indicating inadequate cleaning and maintenance. These conditions were not in accordance with professional standards for food storage and safety. Dietary staff were observed not adhering to proper hand hygiene and glove usage protocols. Staff members were seen handling food with contaminated gloves after touching dirty objects, such as trash can lids, without washing their hands. This included instances where staff used the same gloves to handle both dirty and clean items, such as cutting and serving food, which could lead to cross-contamination. The facility's policy on handwashing and glove usage was not followed, as staff did not wash their hands before handling food or clean equipment. The facility also failed to maintain the physical environment of the kitchen in a clean and sanitary condition. Observations included stained ceiling tiles, rust-stained vents, chipped walls, and loose baseboards. Additionally, hot food items were not maintained at the required temperature of 135 degrees Fahrenheit or above, with several food items being served at significantly lower temperatures. The facility's policy on the use of leftovers was also not adhered to, as leftover foods were used for pureed diets, contrary to the policy guidelines.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that enhanced barrier precautions (EBP) were consistently followed to prevent the spread of possible infection for a resident. The resident had multiple diagnoses, including gastrostomy, cerebral infarction, bipolar disorder, diabetes mellitus type 2, and Alzheimer's disease. Despite the presence of EBP signage on the resident's door and a stocked PPE cart, staff members were observed providing care without using the required PPE. Specifically, a Certified Nursing Assistant (CNA) was seen performing incontinent care without PPE, and a Hospice CNA bathed the resident without PPE, claiming it was her first time working with the resident and she was unaware of the EBP requirement. The facility's policy for EBP mandates the use of gloves and gowns during high-contact activities such as bathing, incontinent care, and when a resident has an indwelling device. The policy also requires signage and availability of PPE outside the resident's room. Interviews with other staff members confirmed they had been educated on EBP and understood its purpose and implementation. However, the lack of adherence to these precautions by some staff members led to the deficiency, as they failed to follow the established infection prevention and control measures.
Failure to Implement Positioning Device for Contracture Prevention
Penalty
Summary
The facility failed to ensure that a care-planned positioning device was in place to prevent further contracture for a resident who had a cerebrovascular accident (CVA) affecting their left non-dominant side. The resident was cognitively intact, as indicated by a Brief Interview of Mental Status (BIMS) score of 15. The care plan, revised on January 4, 2023, included an intervention to place a carrot in the resident's left hand to prevent contracture. However, during multiple observations on January 13, 14, and 15, 2025, the surveyor noted that no positioning device was in place, and a hand roll was observed on the nightstand instead. The Licensed Practical Nurse (LPN) stated that Hospice had instructed them to discontinue the use of the carrot due to a past fracture of the resident's index finger, but no documentation was provided to support this order. The Director of Nursing (DON) later provided a care plan from Hospice, which did not address the contracture issue. Additionally, a review of the facility's Range of Motion Exercise policy, revised in October 2010, did not contain any pertinent information regarding the deficient practice.
Failure to Attempt Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that gradual dose reductions (GDR) for psychotropic medications were attempted for a resident using anti-anxiety medication, specifically a benzodiazepine, without a physician's documented evaluation of the specific risks versus benefits of continuing the medication past 14 days. The resident, identified as cognitively intact with a Brief Interview of Mental Status (BIMS) score of 15, had an order for the medication to be administered every four hours as needed (PRN). However, there was no documentation in the resident's electronic medical record regarding attempts at dose reduction or any justification for not attempting a reduction. The Director of Nursing (DON) acknowledged the deficiency, indicating that the facility would have to accept the tag for the resident taking the anti-anxiety medication beyond the 14-day period without the necessary physician documentation to extend the medication. The facility's policy on Drug Regimen Review requires a monthly review and analysis of prescribed medication therapy, with findings and recommendations reported to relevant staff, but this process was not adequately followed in this case.
Inadequate Pureeing of Food for Residents on Pureed Diets
Penalty
Summary
The facility failed to ensure that pureed food items were blended to a smooth, lump-free consistency for residents requiring pureed diets, as observed during a meal service. On January 13, 2025, at 11:22 AM, a dietary staff member, DC #7, attempted to puree boiled, seasoned squash but ended up with a runny consistency despite adding a cup of thickener. The pureed squash remained thin when served to residents. Later, at 11:51 AM, DC #7 attempted to puree pepperoni pizza by adding tomato sauce and tomato juice, but the mixture contained pieces of pizza and was not smooth. During an interview at 1:15 PM, DC #7 acknowledged that the pureed squash was thin and the pureed pizza contained pieces, indicating insufficient blending.
Sanitation and Hygiene Deficiencies in Kitchen and Food Storage Areas
Penalty
Summary
The facility failed to maintain proper sanitary conditions in the kitchen and food storage areas, which had the potential to affect 75 residents who received meals from the kitchen. Observations revealed that trash cans with various stains were stored near food prep areas and food storage racks, and a kitchen sink had leaks with a bucket collecting dirty water. The walk-in freezer had ice buildup on the floor and shelves, and the chest freezer lacked a thermometer and was covered in ice. Opened food items in the refrigerator, freezer, and storage room were not covered, sealed, or dated, and expired foods were not promptly removed, increasing the risk of cross-contamination. The ice machine and ice scoop were not maintained in clean and sanitary conditions, with residues observed in areas where ice touches before dropping into the collector. The ice machine was used by CNAs for residents' water pitchers and in the kitchen for beverages served to residents. Dietary staff failed to practice good hand hygiene, as observed when a dietary staff member handled food and clean equipment without washing hands after touching dirty objects. Additionally, hot food items were not maintained at the required temperature on the steam table, with pureed chicken tender recorded at 116 degrees Fahrenheit. The facility's dietary staff did not adhere to proper hand hygiene protocols, as evidenced by multiple instances where staff members handled food and clean equipment without washing hands after touching dirty objects. This included using contaminated gloves to handle food and clean equipment, and failing to wash hands after engaging in activities that contaminated the hands. The facility's hand washing policy was not followed, which documented the need for hand washing during food preparation and after engaging in activities that contaminate the hands.
Failure to Refund Deceased Residents' Funds Timely
Penalty
Summary
The facility failed to ensure that refunds were issued to the responsible parties of two deceased residents within 30 days of their discharge. During an interview, the surveyor requested bank statements for the two residents, which showed that Resident #230 had a balance of $1,510.87 and Resident #231 had a balance of $407.00, with no charges deducted from these accounts. A review of the medical records revealed that both residents had passed away in the facility. The facility's Business Office confirmed a process failure in returning the funds to the deceased residents' families. The facility's policy requires that funds be conveyed within 30 days of a resident's death, but this was not adhered to in these cases.
Failure to Secure Hazardous Chemicals in Facility
Penalty
Summary
The facility failed to ensure that certain areas, specifically the G Hall shower room and the beauty shop, were secured to prevent residents from accessing potentially harmful chemicals. During observations, the surveyor noted that the shower room door was slightly open, with uncapped gallon jugs of shampoo and personal cleanser accessible. A CNA confirmed that residents could potentially enter the room and ingest these chemicals. Similarly, the beauty shop was found unlocked with various chemical products, such as disinfectant spray and uncapped hairspray, left on the counters and in unlocked cabinets. A Restorative Aide acknowledged that the beauty shop should be locked to prevent residents from accessing these products. Additionally, the surveyor observed an open closet and an unattended office containing Dakin's solution, oxy cleaner, wound cleanser, and antimicrobial soap. An LPN confirmed that the office door was never closed or locked, and acknowledged the presence of these chemicals, which could be harmful to residents. The Director of Nursing admitted that there was no existing policy or procedure for securing the shower rooms or beauty shop, highlighting a systemic issue in maintaining a safe environment for residents.
Failure to Administer Oxygen at Prescribed Rate
Penalty
Summary
The facility failed to administer oxygen at the physician-ordered rate for two residents, leading to potential respiratory complications. Resident #60, diagnosed with chronic obstructive pulmonary disease (COPD), heart failure, and atrial fibrillation, was observed receiving 2 liters of oxygen instead of the prescribed 3 liters. This discrepancy was confirmed by both the resident and Licensed Practical Nurse (LPN) #3, who acknowledged the error and stated that the supervising Registered Nurse (RN) should check oxygen settings. The Director of Nursing (DON) also confirmed that nurses are responsible for ensuring oxygen is administered correctly and should check the settings daily. Similarly, Resident #25, with diagnoses of COPD with acute exacerbation and acute respiratory failure, was observed receiving 2.5 liters of oxygen instead of the prescribed 3 liters. This was confirmed by LPN #2, who acknowledged the discrepancy between the observed oxygen rate and the physician's order. The facility's policy on oxygen administration requires verification of physician orders and adherence to facility protocols, which was not followed in these instances.
Inadequate Monitoring of Resident on Anticoagulants
Penalty
Summary
The facility failed to ensure that staff were adequately trained to monitor residents on high-risk medications, specifically anticoagulants like Apixaban (Eliquis). This deficiency was identified through the case of a resident with severe cognitive impairment and a diagnosis of unspecified atrial fibrillation, who was taking both an antidepressant and an anticoagulant. The resident exhibited bruising on both arms, which was not documented or addressed by the staff, indicating a lack of proper monitoring and documentation. During the survey, it was revealed that skin audits, which are supposed to be conducted weekly to identify skin concerns such as bruising, were not completed for the resident. Licensed Practical Nurses (LPNs) and Certified Nursing Assistants (CNAs) were unaware of the bruising and had not been informed of the need to monitor for adverse effects of the anticoagulant medication. The facility's care plan for the resident included instructions to observe and report adverse reactions to anticoagulant therapy, but these were not effectively communicated or followed by the staff. Interviews with various staff members, including LPNs, CNAs, and the Director of Nursing (DON), revealed a lack of training and understanding of how to access and utilize care plans and electronic systems to monitor residents on high-risk medications. The DON admitted that there was no retraining to ensure competency in accessing care plans, and the facility could not provide documentation that aides were trained on monitoring residents taking high-risk medications. This lack of training and communication led to the oversight in monitoring the resident's condition and addressing the bruising observed by the surveyor.
Failure to Conduct Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed a monthly Medication Regimen Review (MRR) for several residents, as required by their policies and procedures. Specifically, the facility could not provide documentation of completed MRRs for four residents, indicating a lapse in compliance with regulatory requirements. The Director of Nursing (DON) acknowledged the absence of these records during the surveyor's review. For Resident #41, the facility did not have MRR recommendations documented for several months, despite the resident having significant medical diagnoses, including respiratory failure, type II diabetes mellitus, and major depressive disorder. The resident's cognitive impairment was also noted, with a Brief Interview for Mental Status (BIMS) score indicating severe cognitive impairment. The DON was unable to provide the missing MRR documentation for multiple months when requested by the surveyor. Similarly, for Residents #24 and #25, the facility failed to provide evidence of completed MRRs for various months. Resident #24, who was cognitively intact, was on multiple medications for anxiety, pain, and migraines, yet the facility lacked documentation of a gradual dose reduction. Resident #25, with moderate cognitive impairment, was on antidepressants, but the facility did not address insomnia in the care plan. The DON confirmed the absence of MRR documentation for these residents, highlighting a systemic issue in maintaining accurate and complete medication review records.
Medication Storage Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure that medications were stored securely, leading to several deficiencies. During an inspection, it was observed that an oxygen concentrator was used to prop open a door to the Employee Training/Staff Development room, where medications were left unsecured. The room contained unlocked medication carts with various medications, including wound and burn gel, Hibiclens, and prescription medications like Lageviro. The Assistant Director of Nursing confirmed that medications not stored behind a locked door could be taken by residents and should be secured. Additionally, the facility did not prevent medications from being left at the bedside for two residents. Resident #13 had a bottle of TUMs on the bedside table, which was brought in by family without a doctor's order for self-administration. Similarly, Resident #56 had a bottle of Tineacide on the chest of drawers, which was not authorized for self-administration. Both residents were cognitively intact, but the presence of these medications posed a risk as other residents could access them. The Director of Nursing confirmed that no residents had self-administration rights and that families were instructed not to bring medications into the facility. Furthermore, the facility failed to ensure that narcotic medications were stored in a permanently affixed compartment. Inspections of the medication rooms revealed that the locked boxes containing refrigerated controlled medications were not permanently affixed, which was confirmed by multiple nursing staff. The Director of Nursing acknowledged that the locked boxes were not affixed to anything, contrary to the facility's policy that required controlled medications to be stored in separately locked, permanently affixed compartments.
Failure to Adhere to Planned Menu for Residents on Modified Diets
Penalty
Summary
The facility failed to ensure meals were prepared and served according to the planned written menu, which affected residents on pureed and mechanical soft diets. During the noon meal preparation, the dietary staff did not prepare or serve the required gravy and mashed potatoes to residents on these diets. Specifically, the dietary staff pureed cornbread and cabbage but did not prepare enough servings to meet the needs of all residents requiring pureed diets. Additionally, the dietary staff prepared apple cobbler but discarded extra servings instead of ensuring all residents received the correct portion size. The dietary staff admitted to rushing and overlooking the preparation and serving of mashed potatoes and gravy, which were part of the planned menu. This oversight affected 11 residents on pureed diets and 6 residents on mechanical soft diets. The dietary staff acknowledged the need for larger portions for some residents but failed to prepare the necessary extra servings. This deficiency was observed and documented by the surveyor, highlighting the facility's failure to adhere to the planned menu and meet the nutritional needs of its residents.
Inadequate Pureed Food Consistency
Penalty
Summary
The facility failed to ensure that pureed food items were blended to a smooth, lump-free consistency, which is necessary to minimize the risk of choking or other complications for residents requiring pureed diets. During an observation, it was noted that the dietary staff member placed servings of polish sausage, cornbread, and seasoned cabbage into a blender with additional ingredients, but the resulting mixtures did not achieve the required smooth consistency. The pureed polish sausage was lumpy with visible pieces of meat, the cornbread was gritty, and the cabbage was runny and not properly formed. Interviews with staff members, including Certified Nursing Assistants and the Dietary Manager, confirmed the inadequacy of the pureed food consistency. They described the pureed meat as chunky, the cornbread as too thick, and the vegetables as too thin. These observations and staff confirmations indicate that the facility did not meet the dietary needs of residents on pureed diets, potentially affecting 11 residents as documented by the Dietary Supervisor.
Failure to Follow Chopped Meat Diet Orders
Penalty
Summary
The facility failed to adhere to the physician's plan of care for eight residents who required chopped meat diets. During a kitchen observation, it was noted that kielbasa was not pre-chopped as required for these residents. Additionally, three residents were served regular Polish sausage with skin intact, with pieces ranging from 1 to 1.5 inches, which did not meet the prescribed chopped meat diet requirements. The Dietary Manager and a dietary staff member confirmed that the meat pieces were too large. A document provided by the Dietary Manager outlined the requirements for chopped diets, indicating that the food should be soft, bite-sized, and easy to chew, as advised by speech therapy.
Failure to Inform Residents of Arbitration Agreement Rights
Penalty
Summary
The facility failed to ensure that the Binding Arbitration Agreement clearly stated that residents or their representatives were not required to sign the agreement as a condition of admission or to continue receiving care. On July 15, 2024, the Director of Nursing provided a copy of the arbitration agreement used at admission, which lacked the necessary wording to inform residents or their representatives of their right to refuse signing without affecting their admission or care. A review of the arbitration agreements for several residents revealed that the signed contracts did not include this critical statement. Additionally, a social worker confirmed that families were verbally informed they could sign the agreement but were not obligated to do so for admission, yet this was not reflected in the written document.
Infection Control Deficiencies in Water Management and Resident Care
Penalty
Summary
The facility failed to implement a comprehensive water management program to prevent the growth of Legionella and other waterborne pathogens. During the survey, the Maintenance Director admitted that there was no water management plan in place, and the Director of Nursing confirmed this after consulting with the Administrator. The facility relied on city water and did not conduct any flushing of water pipes or other preventive measures. The provided documentation lacked any assessment or control measures for Legionella, indicating a significant oversight in infection prevention. The facility also failed to implement enhanced barrier precautions for a resident with a PEG tube and an open wound. Staff members, including CNAs and an LPN, were not adequately educated on enhanced barrier precautions, and there was no signage indicating such precautions for the resident. The Infection Preventionist acknowledged that residents with indwelling medical devices should be on enhanced barrier precautions, yet this was not practiced, highlighting a gap in staff training and infection control measures. Additionally, the facility did not ensure proper hand hygiene and storage practices to prevent cross-contamination and infection. Staff were observed not performing hand hygiene before assisting residents with meals, and dentures were improperly stored without a lid or cleaner. Furthermore, clean linens were not stored properly, with carts left uncovered, exposing them to potential contamination. These lapses in basic infection control practices further demonstrate the facility's failure to maintain a safe and hygienic environment for its residents.
Inconsistent Use of Hand Device for Resident with Contracture
Penalty
Summary
The facility failed to ensure that a hand device, specifically a right palm guard, was consistently used for a resident with a hand contracture. The resident, who had hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, was observed multiple times without the palm guard in place. Despite having a physician's order for the palm guard to be worn during the day, the resident was seen without it on several occasions, and the resident expressed an inability to open the contracted hand without assistance. Interviews with staff revealed a lack of clarity regarding responsibility for ensuring the palm guard was applied. An LPN stated that aides were responsible for applying the device, while nurses were to follow up. The Director of Nursing confirmed that nurses were responsible for ensuring aides applied the splints. The facility's policy on Activities of Daily Living (ADL) emphasized providing care to maintain or improve residents' abilities, yet the failure to apply the palm guard as ordered was evident, potentially leading to further contracture.
Failure to Provide Adequate Dental Care
Penalty
Summary
The facility failed to ensure proper dental care for a resident, identified as Resident #71, who had diagnoses of chronic kidney disease, dementia, and metabolic encephalopathy. The resident's admission Minimum Data Set (MDS) indicated a Brief Interview for Mental Status (BIMs) score suggesting cognitive intactness and required set-up assistance for oral care. During observations, the resident was seen with protruding upper teeth, noticeable yellowing, and a thick white substance on the bottom teeth. Interviews with the resident and a Certified Nursing Assistant (CNA) confirmed the resident required assistance with oral hygiene, including brushing teeth and cleaning dentures. The Director of Nursing (DON) confirmed that all staff, including CNAs, are responsible for ensuring residents receive proper dental care, with nursing ultimately responsible for dependent residents. The facility's policy on denture care and activities of daily living (ADLs) emphasized the need for assistance with oral care for residents unable to perform these tasks independently. Despite these policies, the facility did not provide the necessary assistance to maintain the resident's oral hygiene, leading to the observed deficiency.
Improper Incontinent Care Technique
Penalty
Summary
The facility failed to ensure proper incontinent care for a resident, leading to a potential risk of infection. The resident, who had hemiplegia, hemiparesis, and dementia, was always incontinent of bowel and bladder. During an observation, it was noted that two CNAs did not use the proper technique or sufficient supplies while providing incontinence care to the resident. This was confirmed by both CNAs during interviews, acknowledging that the care provided did not adhere to the required standards. The Director of Nursing also confirmed that the proper technique was not used during the provision of perineal care to the resident. The facility's policy on perineal care emphasizes the importance of cleanliness, comfort, infection prevention, and skin condition observation, which were not followed in this instance. The deficiency was identified through observation, interviews, and record reviews, highlighting a lapse in maintaining hygiene standards for incontinent care.
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Two residents with moderate cognitive impairment and independent mobility were repeatedly seeking each other’s attention and were found by a CNA on the floor with their pants down, appearing to be engaged in consensual sexual activity. Staff separated them and returned them to secure units, and an LPN reported there was no plan for a consensual sexual relationship or private time, despite awareness of prior similar behavior. Both residents described themselves as being in a loving relationship, but the facility completed no assessments related to sexual activity, made no related care plan revisions, and obtained no orders for contraception, STD testing, or specialty consults. Conversations held by leadership with the residents about privacy and protection were not documented, and there was no facility policy addressing resident sexual relations, despite a general resident rights policy referencing self-determination and support in exercising rights.
The facility failed to develop and implement comprehensive care plans addressing sexual health and a consensual sexual relationship for two cognitively impaired, independently mobile residents with psychiatric and neurological diagnoses. Both residents were known to seek each other’s attention and had a prior relationship, yet their care plans only directed staff to separate and redirect them, without any individualized interventions for sexual health, privacy, or safe sex. A CNA later found the two residents on the floor with their pants down, appearing to engage in consensual sexual activity, and they were separated by staff. Subsequent staff interviews confirmed there was no documented assessment, no care plan revisions for sexual health or the relationship, no safe sex education, no established access to contraception, and no facility policy on resident sexual relations.
A resident with hemiplegia, hemiparesis, a below-knee amputation, moderate cognitive impairment, and wheelchair dependence was transported in a facility van by a CNA who had previously been in-serviced and skills-checked on van safety. During the trip, the CNA secured only three of the four required wheelchair floor locks, and a hold-down device had been removed from the van and not replaced. As the CNA drove over a road irregularity and braked, the incompletely secured wheelchair tilted backward, causing the resident to fall onto the van floor and report head pain with a nodule at the base of the skull. Facility policy required an environment free from accident hazards and staff competency in preventing avoidable accidents, but the missing tie-down and failure to fully secure the wheelchair led to this transport-related fall.
Surveyors found that the facility failed to follow physician orders for PICC line dressing changes, wound care, and catheter care for two residents. One resident with osteomyelitis, pressure ulcers, and an indwelling catheter had multiple missing entries on the TAR for ordered PICC line dressing changes, daily pressure ulcer treatments to the heel and coccyx, and catheter care every shift, with the DON confirming that blank TAR blocks indicated treatments were not completed. Another resident with a PICC line for antibiotic therapy had an order for weekly dressing changes, but the dressing was not changed as scheduled, the PICC site was left uncovered for several minutes during medication administration, and an LPN admitted initialing the TAR to indicate a dressing change that she had not performed, while the TN and APN confirmed the order required adherence to the weekly schedule.
A resident with MRSA colonization and a PICC line for IV antibiotics experienced multiple breaches in infection control by nursing staff. An LPN repeatedly double-gloved, handled room surfaces, trash can lids, and the medication cart, then donned new gloves without performing hand hygiene before preparing and administering oral and IV medications. During PICC access, the LPN wiped the access port for only a few seconds, allowed IV tubing to touch bedding, let the access port fall onto the resident’s arm, and then re-accessed the line without hand hygiene or glove changes. At another time, the PICC site was left uncovered while a treatment nurse prepared for a dressing change, and the LPN entered without prior hand hygiene, disconnected IV tubing, and flushed the line after only a brief alcohol wipe. Staff interviews showed uncertainty and inconsistency regarding required scrub times, glove use, and dressing change schedules, which conflicted with facility policies and stated expectations for aseptic PICC care and hand hygiene.
A resident with dementia, anxiety, depression, and on hospice had a Durable Power of Attorney, Living Will, and signed DNR order all specifying no CPR, and the face sheet reflected no CPR; however, physician orders, a MD progress note, and the MAR repeatedly listed the resident as full code from admission onward. Nursing staff and leadership (including a RN, LPN, ADON, DON, and the Administrator) acknowledged that while the advance directives and resuscitate/DNR form showed DNR status, the active orders and MAR still indicated full code, even though staff commonly rely on these documents to determine code status, contrary to facility policy requiring alignment of the care plan and physician orders with the resident’s documented treatment preferences.
A resident with depression, insomnia, and non-Alzheimer’s dementia experienced a documented decline from moderate to severe cognitive impairment on successive MDS assessments, but the care plan was not revised and continued to include an active "Sexual Expression" problem allowing engagement in sexual behavior with other consenting residents. This care plan had been initiated after an incident where two residents were found in bed together partially undressed and engaging in intimate behavior. The resident’s responsible party stated the resident was not capable of consenting to sexual activity, an LPN reported the resident could not express needs or make decisions about sexual relationships, and another LPN stated the care plan no longer reflected the resident’s needs due to steady decline. The Social Services Director had previously completed sexual consent questionnaires only at the time of the incident, and the Medical Director indicated that a sexual activity care plan was not appropriate for a resident with a very low BIMS score, while the Administrator acknowledged care plans were expected to be updated when MDS changes occurred.
A resident with traumatic brain injury, stroke history, and altered mental status was placed on a secured unit for elopement risk but had only general care plan interventions that were not updated when new wandering, exit‑seeking, and aggressive behaviors emerged. Over time, staff documented that the resident walked the halls at night, entered other residents’ rooms, voiced not living there, stated plans to leave through a window, followed staff through locked doors, and sought ways to get out after a home visit. Despite an elopement assessment and multiple behavior notes, no individualized elopement‑prevention interventions were added to the care plan. Eventually, during a night shift when a CNA reported dozing off and not re‑checking the room, the resident broke a bedroom window with furniture, left the building, and was later found off‑site by police after nearly being hit by a car, confirming that the care plan had not been effectively revised or implemented to address the resident’s exit‑seeking behaviors.
A resident with traumatic brain injury, altered mental status, and a history of wandering was housed on a locked unit with a care plan identifying elopement risk but focused mainly on therapeutic activities and medication monitoring. After returning from a home visit, the resident exhibited escalating behaviors over several days, including being up all night walking halls, entering other residents’ rooms, standing at locked exits, following staff out locked doors, voicing a desire to leave, and stating a plan to escape through a window. On the night of the incident, camera footage showed the resident moving between the room, day room, and bathroom until entering the room and not re-emerging, while the CNA on duty did not perform checks, reported that staff did not usually re-check the resident once in the room, and admitted to dozing off. The resident broke the bedroom window with furniture, left the building unnoticed, and was later found by police nearly two miles away after a citizen reported almost hitting the resident with a car, demonstrating that the facility failed to provide adequate supervision and monitoring during a period of increased exit-seeking.
Two residents with significant cognitive and neuromuscular/orthopedic conditions experienced falls when staff did not follow care-planned assistance and supervision requirements. One resident, care-planned for two-person assist with bed mobility, transfers, and personal hygiene, was found on the floor after a CNA attempted incontinent care alone. Another resident, care-planned for staff assistance with dressing and two-person assist for transfers with a slide board, was left seated at the edge of the bed and told to dress themself; the resident fell while unattended and was later found on the floor wearing a C-collar. CNAs reported relying on the electronic care plan/Kardex for instructions, but one CNA described unclear and brief initial training on accessing the system, while leadership stated CNAs were expected to verify care needs in the electronic care plan before each care episode.
Failure to Support and Assess Consensual Sexual Relationship Between Residents
Penalty
Summary
The deficiency involves the facility’s failure to support residents’ rights to engage in a consensual sexual relationship between two cognitively impaired residents. Both residents had documented moderate cognitive impairment on their MDS assessments (BIMS scores of 11 and 12) and were independent with mobility. Their care plans identified "inappropriate seeking of other individual's attention" with interventions limited to separating and redirecting them. There was no documented assessment of their capacity for sexual decision-making or sexual activity either before or after an incident in which they were found with their pants down on the floor together. On the date of the incident, a CNA discovered the two residents in a room with their pants down, appearing to be having sex, and reported that it looked like they were consenting and that she had been told they had a history together. The CNA notified an LPN, and the residents were separated and returned to their secure units. The LPN confirmed there was no plan in place to allow a consensual sexual relationship or to provide private time for the residents, despite being aware that similar behavior had occurred previously. Interviews with the residents indicated that they viewed themselves as being in a relationship, that they loved each other, and that they did not intend harm. Record review showed no orders for birth control, sexually transmitted disease testing, or referrals to specialized clinics or physicians for either resident. There was no documentation in progress notes of education or conversations with staff regarding the incident, and no assessments related to sexual activity were completed before or after the event. The MDS nurse and Administrator acknowledged speaking with the residents about the incident and the possibility of providing privacy and protection, but the MDS nurse stated that none of these discussions or interventions were documented and nothing was added to the care plans. The Administrator also stated the facility did not have a policy on resident sexual relations, despite a resident rights policy referencing residents’ rights to self-determination and to be supported in exercising their rights.
Failure to Care Plan for Residents’ Sexual Health and Consensual Relationship
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, measurable care plans addressing sexual health and consensual sexual relationships for two cognitively impaired residents. Resident #3, admitted with traumatic brain injury, bipolar disorder, mood disorder, and an unspecified mental disorder, had a BIMS score of 11 indicating moderate cognitive impairment and was independent with mobility. Resident #4, admitted with schizophrenia, schizoaffective disorder bipolar type, dementia, and psychosis, had a BIMS score of 12, also indicating moderate cognitive impairment, and was independent with mobility. Both residents’ care plans, updated on 03/11/2026, identified “inappropriate seeking of other individuals’ attention,” but the only interventions listed were to separate and redirect, with no individualized care plan addressing their sexual health, their ongoing relationship, or parameters for consensual sexual activity. On 03/11/2026, a CNA discovered Resident #3 and Resident #4 on the floor with their pants down, appearing to be engaged in consensual sexual activity. The CNA notified an LPN, and staff separated the residents and returned them to their secure units. Staff interviews revealed that there was no existing plan for a consensual sexual relationship, no plan for private time, and no documented assessment or care plan interventions related to sexual health, safe sex education, or contraception for these residents, despite knowledge of a prior relationship and the residents’ expressed desire and intent to engage in sexual activity. The MDS nurse and the Administrator acknowledged that no care plan revisions were made to address sexual health or the relationship, no documentation of related discussions or interventions was completed, and the facility had no policy on resident sexual relations and no established interventions for birth control.
Failure to Properly Secure Wheelchair During Van Transport Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s wheelchair was fully and properly secured with all required safety straps before transport in the facility van, resulting in the resident falling backwards in the van. The resident had physician orders for LTC admission and diagnoses including hemiplegia and hemiparesis affecting the right dominant side, as well as an acquired absence of the left leg below the knee. The resident’s MDS showed moderate cognitive impairment, functional limitations in lower extremity range of motion bilaterally, and use of a wheelchair for mobility. The care plan documented a self-care performance deficit requiring limited assistance by one staff for transfers and noted an actual fall earlier in the month, with an intervention for staff education on proper van transport. On the date of the incident, the resident was being transported in the facility van by a CNA who served as the van driver. According to the facility’s reportable and the CNA’s written witness statement, the CNA applied two back floor locks and one front floor lock to secure the wheelchair but did not secure all four required locks. During the drive, as the CNA approached a dip or hump in the road and applied the brakes, the resident’s wheelchair tilted backwards. The resident stated they were falling, and when the CNA stopped the van, she found the resident lying flat on their back on the van floor with the wheelchair also on the floor. Nursing documentation indicated the resident reported pain at the base of the skull, had a nodule on the back of the head, and declined transfer to the emergency room. Interviews and document reviews showed that the CNA had previously received in-service training and skills checkoffs on how to properly secure residents in the van and had signed best-practice forms stating that wheelchairs would be securely attached to the van body and kept centered during transport. The Administrator reported that the CNA admitted she did not use the correct number of straps to secure the wheelchair and that a hold-down device (tie-down/safety strap) had been removed from the smaller van to be used in a larger van and was not replaced. The Maintenance staff confirmed that a hold-down device for the back of the wheelchair was missing from the van used for the transport and that tie-downs were interchangeable between vans. Subsequent observation with other CNAs demonstrated that when all four locks and the seat belt were properly engaged, the wheelchair did not move, but loosening the front locks allowed the wheelchair to move, illustrating how incomplete securement could permit wheelchair movement during transport. The facility’s Safety and Supervision of Residents policy stated that the environment should be made as free from accident hazards as possible and that employees should be trained and demonstrate competency in identifying and preventing accident hazards. Despite this policy and prior in-services, the resident’s wheelchair was not fully secured with all required straps at the time of transport, and a necessary hold-down device was missing from the van, directly contributing to the resident’s fall inside the vehicle.
Failure to Follow Physician Orders for PICC Line, Wound, and Catheter Care
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for PICC line dressing changes, wound care, and indwelling catheter care for two residents. One resident was admitted with osteomyelitis of the vertebra, sacral and sacrococcygeal region, type 2 diabetes mellitus, and a pressure ulcer, and had a BIMS score indicating moderate cognitive impairment. Physician orders included a PICC line dressing change every three days, daily dressing changes to an unstageable right heel pressure ulcer, daily cleansing and dressing of an unstageable coccyx pressure ulcer, and catheter care every shift and PRN with soap and water or wipes for wound healing. Review of the Treatment Administration Record (TAR) for June showed multiple dates where there were no initials or check marks to indicate that the PICC line dressing changes, right heel dressing changes, coccyx pressure ulcer treatments, and catheter care had been completed as ordered. The TAR for this resident showed no documentation of PICC line dressing changes on several specified dates, despite an active order for changes every three days. Similarly, the TAR lacked initials or check marks for the ordered daily dressing changes to the right heel pressure ulcer on multiple dates. For the coccyx pressure ulcer, there were two separate orders—one to cleanse and apply wet-to-dry dressings with a specific brand dressing and island dressing every day shift, and a later order to cleanse and apply wet-to-dry dressings with a specific brand dressing and foam dressing every day shift. On several dates, the TAR contained open blocks with no initials or check marks, indicating that these treatments were not completed. Additionally, the TAR showed that catheter care ordered every shift and PRN was not documented as completed on multiple day shifts over a series of days. The DON confirmed that open blocks on the TAR indicated treatments were not completed. For the second resident, who was admitted with infection and inflammatory reaction due to an internal left hip prosthesis, MRSA, and pain related to orthopedic prosthetic devices, there was an order for a PICC line dressing change to the left upper arm every Wednesday on the day shift. The March TAR reflected this order and showed documented dressing changes on two Wednesdays, with check marks and initials indicating the treatment had been administered. During a medication pass observation, an LPN examined the PICC line dressing and was unsure of the last dressing change date, noting that the handwritten date on the dressing was unclear and that PICC line dressings could only be changed by an RN. Later observation showed the treatment nurse at the bedside with the PICC line site uncovered after the dressing had been removed, while the LPN administered oral medications and hung an antibiotic through the PICC line, leaving the site uncovered for several minutes. The treatment nurse stated the dressing change had been due the previous day but was not completed because the dressing was not available, and also stated she signed the TAR after completing the dressing change. Further interviews revealed documentation discrepancies for this second resident. The DON’s nursing incident/accident note documented that the PICC line dressing change was not completed on the scheduled day and was instead changed the following day. The LPN later acknowledged that the initials on the TAR for the scheduled dressing change date were hers, and admitted she had not changed the dressing but had only looked at it after being told by the treatment nurse that the dressing was within a seven-day time frame. She stated she placed her initials in the TAR block to indicate she had looked at the dressing, even though the TAR coding indicated that initials in the block meant the treatment was given. The treatment nurse reported changing the dressing on one earlier date and, when changing it later, observed a written date on the removed dressing that did not match any documented TAR entry and could not identify whose initials were on that dressing. The treatment nurse and APN both confirmed that the physician’s order required the dressing to be changed every Wednesday and that, even if changed on another day, it still needed to be changed on Wednesday per the order. The DON confirmed that staff initials in a TAR block indicated the treatment was given, an X indicated the treatment was not ordered for that day, and an open block indicated the treatment was not completed.
Improper Hand Hygiene and PICC Line Management During MRSA-Positive Resident Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper infection prevention and control practices during the care of a resident with a PICC line and MRSA colonization. The resident was admitted with diagnoses including infection and inflammatory reaction due to an internal left hip prosthesis, MRSA, and pain related to orthopedic prosthetic devices. The resident had a PICC line in the left arm for IV antibiotic therapy to treat the hip infection, and the care plan included contact isolation, use of gowns and gloves during physical contact, handwashing before leaving the room, and standard precautions for infection control. Orders and the TAR showed that PICC line dressings were to be changed weekly, and the MAR showed daily IV antibiotic administration. Surveyor observations on one morning showed that an LPN performed hand hygiene and donned two pairs of gloves along with other PPE before entering the resident’s room to obtain blood pressure and administer medications. The LPN entered the room multiple times, repeatedly double-gloving, and handled the blood pressure cuff, trash can lid, medication cart, and medication cards without performing hand hygiene between glove removal and donning new gloves. At one point, the LPN removed gloves, closed the trashcan lid with a gloved hand, then removed gloves and immediately donned a clean pair without hand hygiene before preparing and administering the resident’s oral medications. Later, when preparing to administer IV antibiotic through the PICC line, the LPN again donned PPE, placed supplies on paper towels on the overbed table, removed the cap from the PICC access port, and wiped the port with an alcohol pad for less than three seconds before flushing with normal saline. During this process, IV tubing touched the resident’s bedding, the access port fell back onto the resident’s arm, and the LPN discarded the contaminated tubing, obtained new tubing, and again wiped the access port for less than three seconds before attaching the tubing and starting the IV medication, without performing hand hygiene or changing gloves during the sequence. A subsequent observation the same day showed the treatment nurse at the bedside with the resident’s PICC line dressing removed, leaving the site uncovered while the resident looked at the open site and was not wearing a mask. The LPN entered without performing hand hygiene before donning PPE, administered oral medication, disconnected the IV tubing from the PICC line, wiped the access port for three seconds, and flushed with normal saline. The treatment nurse stated responsibility for PICC dressing changes and believed the last dressing change had occurred the prior week, but also reported that the dressing removed that day was marked with a date indicating it was due for change the previous day and that the dressing had not been changed because supplies had to be ordered. Facility records showed that the TAR had been signed for a PICC dressing change on a scheduled day, while later nursing documentation described that a dressing change ordered for a specific day had not been performed as ordered. Facility policies and CDC-based documents required hand hygiene before and after glove use, hand hygiene after glove removal, and disinfection of needleless access devices for at least 15 seconds, and the DON stated that the PICC port should be cleaned for 15 seconds and that the dressing should be in place before starting medication, which contrasted with the observed practices. Interviews with the LPN revealed that double gloving was used so gloves would not have to be changed as often, and the LPN acknowledged that hand hygiene should have been performed after removing gloves and before donning new ones. The LPN initially could not state the required length of time for scrubbing the PICC access port and later stated it should have been cleaned for at least 15 seconds, which differed from the observed practice of wiping for less than three seconds. The treatment nurse described limited availability of PICC dressing kits and that no specific person was responsible for ordering them, and reported having changed the resident’s PICC dressing two to three times since admission. The APN and DON both stated expectations that PICC sites and access ports be kept sterile or clean during medication administration and flushing, that staff use only one set of gloves at a time with handwashing between glove changes, and that the PICC port be cleaned for 15 seconds with alcohol swabs even when medicated caps are used. These expectations and policies contrasted with the observed failures in hand hygiene, glove use, PICC port disinfection, and maintaining an intact dressing prior to accessing the PICC line.
Inconsistent Documentation of DNR Status in Medical Record
Penalty
Summary
The facility failed to ensure that one resident’s medical record accurately and consistently reflected the resident’s advance directive specifying no Cardiopulmonary Resuscitation (CPR). The resident had non-Alzheimer’s dementia, anxiety, depression, moderate impairment in decision-making, and was receiving hospice services. Documentation in the record included a Durable Power of Attorney for Health Care, a Living Will Declaration, and a Resuscitate/Do Not Resuscitate order, all indicating that CPR and chest compressions were to be withheld and that the resident was a Do Not Resuscitate (DNR). The resident’s face sheet also indicated an advance directive for no CPR. Despite these documents, multiple parts of the electronic health record and physician documentation identified the resident as a full code. Physician’s orders from admission onward, including after the resident was admitted to hospice, contained orders indicating full code status. A MD progress note also documented the resident as a full code, and the Medication Administration Record (MAR) for the reviewed period listed the resident as full code. These entries conflicted with the existing DNR orders and advance directive documents in the record. Interviews with nursing staff and leadership confirmed awareness of the discrepancy between the resident’s documented advance directives and the active physician orders and MAR entries. A RN, an LPN, the ADON, the DON, and the Administrator each acknowledged that the resident’s advance directives and resuscitate/do not resuscitate order indicated DNR status, while the current physician orders and MAR showed full code. Staff stated that code status is typically verified using the medical record, MAR, and face sheet, and they recognized that the inconsistency meant staff could rely on incorrect information about whether to initiate CPR. Facility policy required that advanced directives be respected, that the plan of care be consistent with documented treatment preferences, and that the physician be notified so appropriate orders could be documented in the medical record and care plan, which did not occur in this case.
Failure to Revise Sexual Expression Care Plan After Cognitive Decline
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive care plan after a significant decline in cognitive status and changes documented on the quarterly MDS. One resident with active diagnoses of depression, insomnia, and non-Alzheimer’s dementia had a BIMS score of 09 on the 07/30/2025 quarterly MDS, indicating moderate cognitive impairment, which later declined to a BIMS score of 03 on the 01/05/2026 quarterly MDS, indicating severe cognitive impairment. Despite this documented decline, the resident’s care plan continued to include an active problem of “Sexual Expression,” initiated on 08/15/2025 after an incident in which the resident was found in another resident’s bed with both residents partially undressed and engaging in intimate behavior. The care plan goal was to allow the resident to engage in sexual behavior with other consenting residents, with interventions focused on ensuring appropriate consent, providing privacy, and observing for changes in mood or cognition. Interviews and record reviews showed that the care plan was not updated to reflect the resident’s current cognitive status or capacity for consent. The resident’s responsible party stated that the resident was not capable of consenting to sexual relationships or activity and had not been capable for a long time, and identified themselves as the decision maker. An LPN familiar with the resident reported that the resident could not express needs or wants and did not believe the resident was ever capable of making decisions about a sexual relationship, despite what was documented on the care plan. Another LPN stated that the current care plan was not accurate due to the resident’s steady decline. The Social Services Director reported completing sexual consent questionnaires for both involved residents at the time of the original incident and determining they could consent, but acknowledged the form was not set to repeat on subsequent assessments. The Medical Director stated that a care plan for sexual activity for a resident with a BIMS score of 03 was not appropriate because sexual knowledge would be low, and the Administrator confirmed that care plans were expected to be updated quickly when the MDS reflected a change, underscoring that this did not occur for this resident’s sexual expression care plan.
Failure to Update Care Plan for New Exit-Seeking Behaviors Leading to Elopement
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement an effective, updated comprehensive care plan with individualized interventions in response to new onset wandering, exit‑seeking, and elopement‑related behaviors for a resident on a secured unit. The resident had a history of traumatic brain injury, cerebral infarction (stroke), altered mental status, and was admitted to the secured unit due to traumatic brain injury and elopement risk. A quarterly MDS showed the resident was cognitively intact with a BIMS score of 12 and independent with ambulation, but a later BIMS showed a score of 2, indicating moderately impaired cognition. Despite these changes and the resident’s known elopement risk, the care plan initiated months earlier contained only general interventions such as therapeutic activities and medication monitoring, and no additional or revised interventions were added after 08/25/2025 to address later‑emerging behaviors or elopement attempts. On 01/13/2026, multiple progress notes documented significant behavioral changes and explicit exit‑seeking behavior. Early that morning, staff recorded that the resident was up all night walking the halls, refusing to go to bed, entering other residents’ rooms, and voicing that they did not live in the facility. The resident stated an intent to get out of the window. Later that day, another note documented that the resident had been seeking elopement since returning from a home visit, admitted a desire to leave, had been looking for ways to get out, and followed staff out locked doors, showing force when staff tried to return the resident to the unit. A further note that evening described the resident talking loudly, being aggressive toward staff, and again stating a desire to get out of the facility. Although an elopement assessment was completed at that time, there were no new care plan interventions put in place to guide staff in preventing exit‑seeking or managing the aggressive behaviors. In the weeks that followed, staff interviews and documentation showed that the resident continued to exhibit wandering and exit‑seeking behaviors without corresponding care plan revisions. Staff reported that after a family home visit, the resident began trying to leave the unit, walked door to door asking how to get out, watched staff to see if they were paying attention, and talked about leaving. On the night of the elopement, camera footage showed the resident repeatedly moving between the room, day room, and bathroom before entering the room and not re‑emerging. A CNA on duty stated that the resident had been going in and out of the room earlier in the shift, then went back to the room and was not checked on again; the CNA also reported dozing off during the shift and not hearing the window break. In the early morning hours, staff discovered the resident’s window busted and the resident missing, and a progress note documented that the resident had eloped by throwing an end table through the window. A police report and interviews confirmed that the resident was found off‑site after nearly being struck by a vehicle, having left the facility to find family. Throughout this period, the facility did not update the resident’s care plan with individualized, effective interventions to address the clearly documented new onset wandering, exit‑seeking, and elopement behaviors.
Removal Plan
- Revise Resident #1's care plan to include individualized elopement prevention interventions updated to include all interventions per the Plan of Removal.
- Complete new elopement risk assessments for residents residing on the secured unit.
- For any resident scoring moderate or high risk, review care plans to ensure individualized elopement interventions are present.
- Complete environment exit safety checks.
- Revise and update all secured unit residents' care plans based on the Plan of Removal.
- Provide in-service education to nursing and direct care staff on the elopement policy and missing resident procedures.
- Provide in-service education to nursing and direct care staff on the definition and examples of elopement and exit-seeking behaviors, early warning signs requiring interventions, and requirements to notify the nurse, administrator, or DON of new or increased behaviors.
- Provide in-service education to nurse management responsible for updating care plans on mandatory care plan revision following behavior changes with individualized interventions.
- Order shatter-resistant film for front-facing secured unit windows and install it.
- Implement monitoring for the DON or designee to review the 24-hour report to identify new or increasing exit-seeking behaviors.
- Implement monitoring for the DON or designee to complete audits to verify elopement risk assessments are completed, individualized interventions are present, and documentation reflects staff implementation, then transition to routine QAPI monitoring.
Elopement from locked unit due to inadequate supervision and response to exit-seeking behaviors
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain an environment free from accident hazards for a resident with known wandering and elopement risk, resulting in an elopement through a broken bedroom window. The resident had a history of traumatic brain injury, cerebral infarction, altered mental status, and wandering, and had been admitted to a secured unit due to elopement risk. An MDS assessment earlier in the year showed the resident as cognitively intact and independently ambulatory, but a later BIMS assessment showed moderately impaired cognition. The resident’s care plan identified the need for placement on a secured unit related to traumatic brain injury and elopement risk, with interventions focused on therapeutic activities and monitoring of psychotropic medications, but did not include enhanced supervision measures in response to escalating exit-seeking behaviors. In the weeks prior to the elopement, multiple progress notes and staff interviews documented increased exit-seeking and behavioral changes after the resident returned from a home visit. On one day, progress notes recorded that the resident was up all night walking the halls, going in and out of other residents’ rooms, voicing that they did not live in the facility, and stating an intention to get out through a window. Staff documented that the resident had been seeking elopement since returning from a home visit, had been looking for ways to get out, followed staff out locked doors, and showed force when staff tried to return the resident to the unit. Another note from the same day described the resident talking loudly, being aggressive toward staff, and repeatedly expressing a desire to leave the facility. An elopement assessment documented that the resident ambulated independently, had a history of following staff and others, and had been wandering halls and standing by locked exit doors after returning from home. On the night of the elopement, camera footage showed the resident repeatedly moving between the resident’s room, the day room, and the bathroom until entering the room at approximately 3:12 a.m. and not re-emerging. Staff interviews revealed that the CNA assigned to the unit acknowledged that the resident had been trying to start a fight with another resident for two days, that the resident typically went in and out of the room throughout the night, and that staff did not normally go back to check on the resident once the resident returned to the room. The CNA reported that she did not check on the resident after the last interaction around 9:30–10:00 p.m., that she sometimes could not take breaks due to staffing, and that she dozed off for about 30 minutes during the shift. The DON later stated that the CNA reported falling asleep and not hearing the window break. Staff discovered the broken window only when an LPN returned from break around 4:25 a.m., at which point the resident was found to be missing. Law enforcement records and interviews confirmed that the facility reported the resident missing in the early morning hours and that the resident was located off-site by police after a citizen reported almost striking the resident with a vehicle. The police officer stated that the resident was found near a school approximately 1.9 miles from the facility, requiring travel across an intersection and along areas without sidewalks. The resident told police they were walking to find family. Interviews with multiple CNAs and nurses indicated that the resident had been going door to door asking how to get out, watching staff to see if they were paying attention, and walking back and forth to doors after returning from a family visit. The DON and Administrator both stated they were not aware of prior elopement attempts beyond wandering and walking back and forth, and the MDS Coordinator reported she had not been informed of the January incident in which the resident voiced a plan to escape through a window. Facility policies required staff to know the location of residents under their care and to implement care plan strategies for residents at risk of wandering or elopement, but staff interviews showed that routine checks were not performed on the resident during the night of the incident and that the resident’s escalating exit-seeking behaviors were not effectively communicated or translated into increased supervision. A police incident report and witness statements further detailed that the resident exited the building by throwing an end table through the bedroom window. The facility’s own missing resident and wandering/elopement policies stated that staff are responsible for knowing residents’ whereabouts and that care plans for at-risk residents must include safety strategies and interventions. Despite documented behaviors such as wandering, standing at locked doors, following staff out locked exits, verbalizing intent to leave, and specifically stating a plan to get out through a window, there was no evidence in the record that supervision was increased or that staff adjusted monitoring practices during periods of heightened exit-seeking. Staff interviews also revealed that for several weeks there had often been only one CNA on the locked unit at night, and that the CNA on duty the night of the elopement positioned herself in a doorway with hall lights off and later admitted to dozing off. These actions and inactions resulted in the resident being able to break the window, leave the secured unit and facility, and travel a significant distance off-site before being located and returned by police.
Failure to Follow Care-Planned Assistance and Supervision Leading to Resident Falls
Penalty
Summary
Facility staff failed to follow care-planned interventions for assistance and supervision for two residents, resulting in falls. Resident #2, admitted with Alzheimer's disease, spastic hemiplegic cerebral palsy, and neuromuscular bladder dysfunction, had a care plan requiring assistance of two staff for bathing/showering, bed mobility, personal hygiene, toilet use, and transferring. On 06/04/2025, the DON and an LPN responded to Resident #2's room and found the resident on their back on the floor after CNA #1 attempted to perform incontinent care alone, contrary to the care plan specifying a two-person assist for bed mobility, transfers, and personal hygiene. CNA #1 later stated that, upon hiring, it was not made clear how to access the electronic care plan system and that initial training on the system was brief and difficult to see. Resident #3 was admitted with spinal stenosis of the cervical region, cervical disc disorder with radiculopathy, generalized muscle weakness, and was receiving surgical aftercare following nervous system surgery. The care plan required assistance of one staff member for toileting, bathing/showering, dressing, and bed mobility, and assistance of two staff members for transferring, including use of a sliding board with two-person assist. A progress note documented that on 01/15/2026, an LPN was called to Resident #3's room and found the resident lying face down on the floor wearing a cervical collar, after the resident reported being told to dress themself. The resident later recounted that a CNA had helped them to a seated position at the edge of the bed, then left the room with another staff member while the resident attempted to dress themself, during which time the fall occurred. Interviews with multiple CNAs and facility leadership confirmed that CNAs were expected to obtain resident care instructions from the electronic care plan/Kardex system and that Resident #3 required staff assistance for all tasks except meals. CNA #2 acknowledged leaving Resident #3 unattended while assisting another staff member, despite the electronic care plan indicating the resident did not perform tasks alone. Another CNA reported sometimes being the only staff member in the room when transferring Resident #3 with a slide board, even though the care plan required two staff. The DON and Administrator stated that aides were trained one-on-one on the electronic care plans after morning huddles and that CNAs were expected to verify care requirements in the electronic care plan before providing care. The Medical Director stated it was his expectation that orders were followed as written in the care plan. Standard of practice cited requires that residents receive treatment and care in accordance with professional standards, the comprehensive person-centered care plan, and residents' choices.
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