Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pierce Memorial Baptist Home, Inc. during CMS and state inspections, most recent first.
Two residents experienced accidents related to inadequate supervision and failure to follow facility policies for safe ambulation and transfers. One resident with weakness and mobility limitations, care planned for assisted ambulation with a rolling walker and gait belt, was assisted in the hallway by a NA without a gait belt, lost balance, and fell, sustaining a left forearm skin tear and a nondisplaced left olecranon fracture confirmed by X-ray. Another resident with severe cognitive impairment and multiple comorbidities, documented as requiring assistance for transfers, was transferred from wheelchair to bed by two NAs while agitated and was subsequently found to have a new skin tear on the left lower leg. Staff interviews and facility policies confirmed that gait belts were required for assisted ambulation and that residents were to receive adequate supervision and appropriate assistive devices to prevent accidents.
Missing Oxygen Order and Care Plan for Resident Using Continuous Oxygen: A resident with asthma, dementia, diabetes, and anxiety was observed using a nasal cannula connected to an oxygen concentrator at 3 LPM, and the resident stated oxygen was used at all times except when going to the bathroom. The chart lacked a physician order for continuous or PRN oxygen, and the care plan and nurse aide care card did not address oxygen use or related interventions, even though staff confirmed the resident had been using oxygen since pneumonia.
Expired medication was found stored in a Level 1 med room when 2 boxes of Mucus Relief ER were observed past expiration. An LPN said nurses and the person stocking meds check for expired items, and the DNS stated expired medication should not be stored in the med room. The consultant pharmacy summary also noted isolated issues with expired meds removed from carts on Unit 2.
A resident with CHF, depression, anxiety, and significant functional dependence reported that an NA was rude and rough during care. The grievance record showed the DNS and SW spoke with the resident, but the SW progress note for the allegation was not found in the chart, and the DNS confirmed the record should have contained a social work note documenting the incident.
Failure to Offer Pneumococcal Vaccine: A resident with DM, dementia, and severely impaired cognition had prior pneumococcal immunizations documented, but the chart lacked evidence that PCV20 was offered on admission or afterward. The IP RN stated the resident was eligible for the vaccine but was marked ineligible because consent from the responsible party was not obtained, and she had not tried again to obtain consent even though she had contacted the responsible party about other vaccines.
A facility failed to ensure MDS assessments accurately reflected a resident’s positive Level II PASRR status and another resident’s correct return-to-facility date after hospitalization. One resident with dementia and other serious diagnoses had an MDS that listed the wrong readmission date, while another resident with anxiety, depression, and psychotic disorder had annual MDSs that incorrectly answered “no” to the PASRR Level II question despite a positive Level II determination. Interviews confirmed the MDS coding should have matched the PASRR record and the resident’s actual return date.
A resident dependent on staff for transfers and personal care, with a history of chronic osteomyelitis and mobility issues, experienced pain during a mechanical lift transfer for a shower. Despite repeatedly refusing to continue due to pain in a previously operated leg, staff proceeded with the transfer and shower, failing to honor the resident's right to refuse treatment as outlined in facility policy.
A resident dependent on staff for transfers was moved using a mechanical lift with a sling that was too small, contrary to care plan requirements. Staff experienced difficulty positioning the resident, causing pain to a previously operated leg, and the resident's leg struck a bedside table during the process. The sling was not properly supporting the resident, and a latch slipped during the return transfer, resulting in a near fall that required staff intervention. The DON confirmed the incorrect sling size and improper placement contributed to the incident.
A resident dependent on staff for transfers was improperly moved using a mechanical lift by two nurse aides, one of whom was in training. The aides used an incorrectly sized sling and did not follow proper procedures, resulting in pain and a near fall for the resident. The facility lacked a formal training protocol for mechanical lift use, and staff training was undocumented and informal, contrary to facility policy requiring trained caregivers and correct equipment.
A resident with a history of accusatory behaviors and multiple psychiatric and neurological diagnoses required two staff members for all care, as specified in their care plan. On one occasion, only one nurse aide provided care, contrary to the care plan and facility policy. The incident was reported after the resident alleged rough handling, and documentation confirmed the care plan was not followed.
A resident with dementia and aortic valve stenosis experienced respiratory issues and a low-grade fever, but the facility failed to notify the on-call provider as required. The LPN informed the RN supervisor, who did not contact the physician or APRN, contrary to the facility's policy.
A resident with dementia and aortic valve stenosis experienced respiratory distress and a fall, but the RN supervisor failed to conduct a timely assessment despite being notified by an LPN. The facility's policy requiring RN assessment for changes in condition was not followed.
The facility failed to properly label, date, and discard expired food items, and did not maintain cleanliness in food storage areas. Observations revealed expired and unlabeled food in the walk-in freezer and refrigerator, as well as sticky stains in the resident's nutritional refrigerator. The FSD and LPN acknowledged these issues, with the FSD responsible for ensuring outdated food was discarded.
A facility failed to develop comprehensive care plans for two residents. One resident on anticoagulant therapy lacked a care plan addressing side effects and monitoring, while another resident using heel floating boots for a foot wound had no documented care plan or order specifying their use. The facility's policies required timely updates to care plans, but these were not implemented, leading to deficiencies in meeting the residents' needs.
A facility failed to develop a comprehensive care plan for a resident identified as an elopement risk. Despite being placed with a wander guard, the resident was found outside alone multiple times, and the care plan did not reflect the elopement risk or the presence of the wander guard. Inconsistencies in monitoring and documentation contributed to the deficiency.
A resident with intact cognition and using a walker was found off the unit multiple times, despite being initially assessed as not at risk for wandering. The facility failed to consistently monitor the placement and functionality of the resident's wanderguard, leading to elopement incidents. Staff interviews revealed a lack of awareness and documentation regarding the resident's elopement attempts, contributing to the deficiency.
A facility failed to maintain sanitary care of nebulizer equipment for a resident with respiratory conditions. The nebulizer machine and components were found uncovered and undated, contrary to policy. Staff interviews revealed that equipment should be dated and stored properly, but records showed a lack of documentation for nebulizer care.
The facility failed to maintain complete hospice records for a resident with congestive heart failure, lacking essential documents like the Plan of Care and Certificate of Terminal Illness. Additionally, another resident's advanced directive consent form was missing from the medical record after a code status change to DNR/DNI. Interviews revealed a lack of clarity and adherence to policies regarding document filing and accessibility.
The facility failed to implement Enhanced Barrier Precautions for residents with MDROs and indwelling devices, despite knowing the deadline. A resident with a history of C-diff was not properly logged or cohorted, contrary to policy. The Infection Preventionist Nurse acknowledged oversight, and the DON expected proper review and cohorting.
A facility failed to review and revise the care plan for a high-risk resident after multiple falls. Despite the resident's history and the facility's policy, the care plan was not updated after falls on four separate occasions, leading to repeated incidents without new interventions.
The facility failed to document complete skin assessments for a resident with potential for impairment to skin integrity. Despite multiple falls and the presence of bruises and skin tears, the necessary assessments, including size, color, and description, were not conducted as required by the facility's policies. Additionally, unexplained puncture marks on the resident's leg were not documented or addressed.
A facility failed to consistently document a high-risk resident's location on observation sheets during every fifteen-minute monitoring. Despite interventions in the care plan, documentation gaps were found on multiple dates and shifts. The DON was unaware of these lapses and confirmed no policy for the monitoring protocol.
Failure to Use Gait Belt and Safely Manage Transfers Resulting in Resident Injuries
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe ambulation and transfers in accordance with its own policies, resulting in accidents for two residents. One resident with anemia, osteoarthritis, weakness, and difficulty walking had a care plan and aide care card directing staff to provide assistance of one for transfers and ambulation using a rolling walker and a gait belt. The admission MDS documented that this resident required extensive assistance for transfers and ambulation and used both a rolling walker and wheelchair, with no prior history of falls. Despite these documented needs and the facility’s policy requiring gait belt use for residents who cannot ambulate or transfer independently, a nursing assistant assisted the resident with ambulation in the hallway without applying a gait belt. During this assisted ambulation without a gait belt, the resident lost balance and fell to the floor while using a rolling walker. Nursing documentation identified that the resident sustained a skin tear to the left forearm and reported left elbow pain rated 7 out of 10. The resident was transferred to the hospital, where imaging showed posterior elbow soft-tissue swelling and a nondisplaced fracture of the left olecranon. Interviews with an LPN, an occupational therapy assistant, and the DNS confirmed that the nursing assistant had not used a gait belt, that the resident required assistance of one for ambulation, and that facility policy required gait belt use for such residents. Staff also stated that the purpose of the gait belt was to allow staff to maintain a secure grasp if a resident lost balance. The deficiency also includes an incident involving another resident with type 2 diabetes mellitus, dementia, venous insufficiency, anxiety, and peripheral vascular disease, who had severe cognitive impairment and required extensive assistance for transfers. The MDS and aide care card documented that this resident was non-ambulatory and required the assistance of one staff member with a rolling walker for transfers. During a transfer from wheelchair to bed performed by two nursing assistants, the resident was noted afterward to have a new skin tear on the left lateral lower leg, measuring 2.5 cm by 1.5 cm. Facility documentation and staff statements indicated that the resident did not have a skin tear prior to the transfer and that the resident had been agitated and “giving them a hard time” during the transfer, with one aide acknowledging they could have waited for the resident to calm down. The DNS confirmed that the skin tear was identified after the transfer and that the resident had been agitated during the transfer, while also stating that the resident should have been free from any type of accident while care was being provided. The facility’s accidents and supervision policy stated that the environment would be maintained free of accident hazards and that each resident would receive adequate supervision and appropriate assistive devices to prevent accidents.
Missing Oxygen Order and Care Plan for Resident Using Continuous Oxygen
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met for Resident #45, whose diagnoses included mild intermittent asthma, type 2 diabetes, dementia, and anxiety. The annual MDS identified moderately impaired cognition, moderate assistance with personal hygiene, supervision with ambulation using a walker, and that the resident was not receiving oxygen therapy. However, during observation the resident was sitting on the side of the bed wearing a nasal cannula connected to an oxygen concentrator at 3 LPM, and stated that oxygen was used at all times except when going to the bathroom. A sign outside the room also indicated oxygen was in use. Review of the physician's orders for the period from December 16, 2025 through March 23, 2026 failed to identify an order for continuous or PRN oxygen therapy. The resident's care plan dated 2/12/26 also failed to identify oxygen therapy or related interventions, and the nurse aide care card did not identify that the resident used oxygen or how to provide care related to continuous oxygen therapy. Staff interviews confirmed that Resident #45 had been using oxygen since pneumonia over a month earlier, that an order for oxygen should have been in place, and that the resident should have had an individualized care plan addressing oxygen use.
Expired Medications Found in Medication Room
Penalty
Summary
The facility failed to store medications appropriately in 1 of 2 sampled medication rooms. During observation of the Level 1 medication room, 2 boxes of Mucus Relief ER were found with an expiration date of 12/20/25. An LPN stated that the nurses and the person who stocks medications check the medication room for expired medication, and the DNS stated that expired medication should not be stored in the medication room. The facility’s medication storage policy directed that medication carts and all medication rooms be routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. The consultant pharmacy summary for February 2026 also noted isolated issues of expired medications removed from the carts on Unit 2 and given to the nurse.
Missing Social Work Documentation for Alleged Rough Care
Penalty
Summary
The facility failed to ensure that social service visits were documented and readily accessible in the medical record for a resident involved in an allegation of mistreatment. Resident #36 had diagnoses including chronic systolic congestive heart failure, depression, anxiety, and adult failure to thrive, and the quarterly MDS identified intact cognition, dependence for transfers, assistance with toileting hygiene and lower body dressing, and incontinence of bladder and bowel. The care plan noted limited physical mobility related to a history of stroke and left hip fracture, with special care needed when turning the resident due to chronic right knee pain. After the resident reported that NA #5 was rude and rough during care and had rolled the resident over like it was a job, the grievance documentation reflected that the DNS and social services spoke with the resident and that the aide was relieved of duties. An attached DNS note stated that the resident was seen with SW #1 to discuss the incident, but review of social services progress notes for February 2026 did not identify any written documentation of the allegation or the social worker visit. SW #1 stated she would have written a note after the visit and that it is usually included in the investigation, but she later could not locate her note. The DNS also stated there should have been a social work note in the resident's record.
Failure to Offer Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure that the pneumococcal vaccine was offered to a resident with type 2 diabetes, dementia, and cognitive communication deficit who had severely impaired cognition on the quarterly MDS assessment. The resident’s immunization record showed prior receipt of PPSV 23 on 10/4/2012 and Prevnar 13 on 4/6/2026 before admission, and the record also indicated the resident was not eligible for PCV 20 because no consent was obtained in 11/2024. However, the immunization record reviewed on 3/25/26 at 11:15 AM contained no documentation that PCV 20 was offered on admission or afterward. During interview, the Infection Preventionist stated it was her responsibility to assess vaccination status and offer the appropriate vaccine on admission and thereafter. She stated the resident was eligible for PCV 20 on admission but was marked ineligible because she could not reach the responsible party to obtain consent. She further stated she had not tried again to obtain consent for the pneumococcal vaccine since admission, even though she had contacted the responsible party several times about influenza and COVID-19 vaccines and could have obtained consent at that time. The facility policy stated pneumococcal immunization status is to be determined upon admission, undocumented or not up to date status is to be offered the vaccine, and informed consent or declination is to be obtained.
MDS Assessments Did Not Reflect PASRR Status or Correct Readmission Date
Penalty
Summary
The facility failed to ensure comprehensive MDS assessments accurately reflected a resident’s positive Level II PASRR screening and correct admission date. One resident with diagnoses including alcoholic cirrhosis of the liver, type 1 diabetes mellitus, dementia, and neoplasm of the digestive organ had a quarterly MDS that identified severe cognitive impairment and extensive assistance needs for toileting, dressing, personal hygiene, and transfers. After the resident expressed suicidal ideation and an intent to harm self by stabbing self, staff checked the room for sharp objects, stayed with the resident, and transferred the resident to the hospital for evaluation when the resident became nonverbal and unresponsive with a flat affect and minimal eye contact. The record showed the resident was out of the facility from 10/12/25 to 10/27/25 and returned by ambulance on 10/28/25, but the entry MDS incorrectly listed the return date as 10/29/25. A second resident with diagnoses including anxiety, depression, and psychotic disorder with delusions had a PASRR Level II outcome determination showing a positive Level II PASRR. However, the annual MDS assessments dated 2/19/25 and 2/16/26 identified intact cognition and answered “no” to the PASRR question asking whether the resident was currently considered by the Level II PASRR process to have a serious mental illness, intellectual disability, or related condition. Interviews with the SW and DNS confirmed that a positive Level II PASRR should have been reflected on the MDS and that the MDS section was the responsibility of the MDS Coordinator/ADNS. The facility’s MDS policy stated that assessments must be accurate and standardized and that staff completing sections must attest to the accuracy of the sections they completed.
Resident's Right to Refuse Treatment Not Honored During Painful Transfer
Penalty
Summary
A deficiency occurred when staff failed to honor a resident's right to refuse treatment during a transfer and shower. The resident, who had diagnoses including chronic osteomyelitis, anxiety, and abnormal gait and mobility, was dependent on staff for transfers and personal care. According to clinical records and interviews, the resident initially agreed to a transfer using a mechanical lift for the purpose of showering, but began to refuse the transfer and shower after experiencing pain in the right leg, which had previously undergone surgery. Despite the resident's repeated requests to stop due to pain, staff continued with the transfer and proceeded with the shower. Documentation and interviews confirmed that one nurse aide continued the transfer process even after the resident expressed refusal and discomfort, while another aide was present and in training. The incident was reported by the resident and corroborated by facility documentation, which indicated that the resident's rights to refuse treatment were not upheld. The facility's own policies and the Residents' Rights documentation specify that residents have the right to request, refuse, and discontinue treatment, which was not followed in this instance.
Failure to Use Correct Mechanical Lift Sling Size During Resident Transfer
Penalty
Summary
A deficiency occurred when staff failed to use the correct size mechanical lift sling during the transfer of a resident who was dependent on staff for all transfers due to limited physical mobility and a history of chronic osteomyelitis, anxiety, and abnormal gait. The resident's care plan required the use of a mechanical lift with two staff for all transfers, but documentation did not specify the appropriate sling size. During a transfer for a shower, nurse aides experienced difficulty positioning the resident, causing pain to the resident's right leg, which had previously undergone surgery. The resident expressed discomfort and attempted to refuse the transfer, but the transfer proceeded with continued difficulty. Interviews revealed that one nurse aide recognized the sling was too small but was overruled by another aide, who insisted on using the same size sling. During the transfer, the resident's leg was not properly supported, resulting in pain and the resident's leg hitting a bedside table. Upon returning from the shower, a latch on the sling slipped off the lift, causing the resident to begin to fall backward, though a staff member intervened to break the fall. The DON confirmed that the wrong sling size was used and that the sling was improperly placed, leading to inadequate support and pain for the resident.
Failure to Train Staff on Proper Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure that staff were properly trained in the use of mechanical lift transfers, resulting in an improper transfer of a resident who was dependent on staff for mobility. The resident, who had chronic osteomyelitis, anxiety, and abnormal gait and mobility, was care planned to require a mechanical lift with two staff for all transfers. On the day of the incident, two nurse aides, one of whom was in training, attempted to transfer the resident using a mechanical lift. The aides used a sling pad that was too small, and the pad was improperly placed, causing the resident's right leg to be unsupported and in pain. Despite the resident expressing discomfort and refusing the transfer, the aides continued, and during the process, the resident's leg was injured and a latch on the lift pad slipped, causing the resident to nearly fall. Interviews revealed that neither aide had previously transferred this resident, and the aide in training took over the transfer process, which was not appropriate. The DON confirmed that there was no formal training protocol for mechanical lift transfers in place at the facility, and that staff were expected to train each other without documentation or structured guidance. Facility policy required that only trained and qualified caregivers perform such transfers and that the proper size sling be used, but these requirements were not met in this instance.
Failure to Follow Care Plan Requiring Two Staff During Resident Care
Penalty
Summary
A deficiency occurred when staff failed to follow the care plan for a resident with a history of making accusatory statements against staff. The resident, who had diagnoses including transient ischemic attacks, mood disorder, and psychotic disorder with delusions, required assistance from two staff members for all care due to their behavioral history. The care plan and nurse aide care card both specified that two staff members should be present during care. However, on the date of the incident, one nurse aide provided care to the resident alone, contrary to the care plan directives. This failure was identified after the resident reported to a nurse that the aide was rough and had shoved them onto the toilet, nearly causing a fall. Documentation and interviews confirmed that the second aide was not present during the care, as required. The Director of Nursing acknowledged that the care plan was not followed, and the facility policy required staff to be informed of their responsibilities regarding care plan interventions. The incident was not substantiated as abuse, but it was determined that the care plan was not properly implemented.
Failure to Notify Provider of Resident's Change in Condition
Penalty
Summary
The facility failed to ensure timely notification to the provider when a resident experienced a change in condition. The resident, who had diagnoses including dementia and aortic valve stenosis, was noted to have an audible wheeze and faint crackles in the lungs, along with a low-grade fever. Despite these symptoms, the RN supervisor and the physician or APRN were not notified of the change in condition as required by the facility's policy. The LPN on duty administered an inhaler and acetaminophen, raised the head of the bed, and encouraged fluids, but only notified the 11 PM to 7 AM supervisor about the resident's status. The RN supervisor acknowledged being informed of the resident's respiratory issues but did not notify the on-call provider, instead passing the information along in the morning report. The APRN confirmed that she was not aware of the resident's condition change and stated that such changes should be communicated to the on-call service provider rather than relying on a fax note. The facility's Change in Condition Policy mandates that the physician or NP be notified of any change in condition, which was not adhered to in this instance.
Failure to Conduct Timely RN Assessment for Change in Condition
Penalty
Summary
The facility failed to ensure a timely RN assessment for a resident who experienced a change in condition. The resident, diagnosed with dementia and aortic valve stenosis, had a moderate cognitive impairment and required assistance with activities of daily living (ADLs). On a specific date, the resident exhibited symptoms of respiratory distress, including audible wheezing and faint crackles in the lungs, and was administered an inhaler and acetaminophen by an LPN. Despite these interventions, the RN supervisor was not notified, and no RN assessment was conducted during the shift when the change in condition was identified. Further review revealed that the resident had shortness of breath and coarse lung sounds earlier in the day, and later experienced a fall, leading to a hospital transfer. Interviews with the LPN and RN supervisor confirmed that the RN was informed of the resident's condition but did not perform the necessary assessment. The facility's policy mandates that an RN must assess and document any change in a resident's condition, which was not adhered to in this case.
Deficiencies in Food Storage and Cleanliness
Penalty
Summary
The facility failed to ensure proper labeling, dating, and disposal of expired food items, as well as maintaining cleanliness in food storage areas. During an observation, several food items in the walk-in freezer were found to be stored in large zip lock plastic containers with expiration dates that had passed. The Food Service Director (FSD) acknowledged that expired food items should not be left in the freezer and that it was her responsibility to ensure outdated food was discarded. Additionally, in the walk-in refrigerator, there were items such as macaroni pasta and open beef base that were either unlabeled or past their expiration date. Further observations revealed issues in the resident's nutritional refrigerator and freezer, where opened juice boxes and ice cream were found without labels, and some ice cream was covered with freezer burn. The refrigerator and freezer also had multiple areas with sticky brown stains. Interviews with the LPN and FSD indicated that housekeeping and dietary staff were responsible for cleaning the resident's nutritional refrigerator, but neither could confirm when it was last cleaned. The facility's Food and Storage Supply Policy mandates that all food items be stored to prevent contamination and that expired or unlabeled food should be discarded.
Deficiencies in Care Planning for Anticoagulant Use and Pressure Relief Devices
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was developed and implemented for Resident #3, who was on anticoagulant therapy for bilateral pulmonary embolism. Despite the resident's severe cognitive impairment and high-risk medication status, the care plan did not include necessary interventions such as monitoring for bleeding, unusual bruising, or changes in mental status. This oversight was acknowledged by the Assistant Director of Nursing Services (ADNS) and the MDS Coordinator, who admitted that the care plan should have been updated to address the side effects and monitoring requirements associated with anticoagulant use. For Resident #26, the facility did not develop a comprehensive care plan to address the use of heel floating boots, which were being used as a pressure-relieving device due to a new wound on the resident's foot. The resident, who had severe cognitive impairment and was non-ambulatory, wore the boots without a documented care plan or physician's order specifying their use, frequency, or skin integrity checks. The Charge Nurse and Wound Nurse both recognized the absence of a care plan and order, indicating that it was their responsibility to ensure these were in place. The facility's policies required the development of a comprehensive person-centered care plan within seven days after the completion of the comprehensive MDS assessment. However, in both cases, the care plans were not updated to reflect the residents' current needs and interventions, leading to deficiencies in the care provided. The lack of documentation and oversight in updating care plans contributed to the failure to meet the residents' medical and nursing needs effectively.
Failure to Implement Comprehensive Care Plan for Elopement Risk
Penalty
Summary
The facility failed to ensure a comprehensive care plan was developed for a resident identified as an elopement risk. The resident, admitted with diagnoses including heart failure and cognitive communication deficit, was found wandering on the first floor shortly after admission. A wander guard was placed on the resident's ankle, and an elopement risk assessment indicated the resident was at risk and required interventions. However, the comprehensive care plan did not reflect the resident's elopement risk or the presence of the wander guard. Despite physician orders to monitor the wander guard every shift, the Treatment Administration Record (TAR) showed inconsistencies in monitoring, and the wander guard was not always in place. The resident was found outside alone on multiple occasions, and the wander guard failed to alarm during one incident. Interviews with staff revealed a lack of documentation and communication regarding the resident's elopement risk and the need for a wander guard, contributing to the deficiency.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident, identified as Resident #66, who was initially assessed as not at risk for wandering. Despite having intact cognition and using a walker for ambulation, the resident was found off the unit on multiple occasions. On one occasion, the resident was found outside alone, and it was noted that the wanderguard was not in place. On another occasion, the resident was found outside with a friend, and although the wanderguard was in place, it did not alarm when the resident left the unit. The facility's documentation revealed inconsistencies in monitoring the wanderguard's placement and functionality. The Treatment Administration Record (TAR) indicated that the wanderguard's battery function was checked nightly, but there was no documentation of checking its placement. Interviews with staff, including the DNS, highlighted a lack of awareness of the resident's elopement attempts and the absence of reportable event reports or investigations into how the resident exited the building. The facility's elopement policy required monitoring and documentation of the elopement bracelet every shift, which was not consistently followed, contributing to the deficiency.
Inadequate Sanitary Care of Nebulizer Equipment
Penalty
Summary
The facility failed to provide sanitary care of nebulizer equipment for a resident diagnosed with chronic obstructive pulmonary disease, obstructive sleep apnea, and anxiety. The resident had an order for Ipratropium-Albuterol inhalation solution to be used as needed for wheezing. During an observation, the nebulizer machine and its components, including the mouthpiece and medicine cup, were found lying uncovered on a windowsill without a date, contrary to the facility's policy. The resident was unable to recall the last time the nebulizer was used, indicating a lack of proper tracking and maintenance of the equipment. Interviews with the nursing staff revealed that the nebulizer equipment should have been dated and stored in a plastic bag to maintain infection control. The facility's policy required that nebulizer sets and tubing be changed weekly and documented accordingly. However, the Treatment Administration Record did not reflect any checks or care of the nebulizer equipment, indicating a lapse in following the established procedures for respiratory care. This oversight in maintaining and documenting the care of respiratory equipment led to the identified deficiency.
Incomplete Hospice and Advanced Directive Records
Penalty
Summary
The facility failed to maintain complete hospice records for Resident #2, who was receiving hospice care for conditions including congestive heart failure, asthma, and difficulty swallowing. The clinical record lacked essential hospice documentation such as the Interdisciplinary Team notes, Plan of Care, Certificate of Terminal Illness, and the Medicare/Medicaid Hospice Benefit Election form. Interviews with facility staff and the hospice manager revealed that the necessary hospice documents were not included in the resident's medical record, and there was a lack of clarity regarding the responsibility for ensuring these documents were filed appropriately. For Resident #55, who had diagnoses including dementia and type 2 diabetes mellitus, the facility failed to ensure that a signed copy of the advanced directives consent form was accessible in the resident's medical record. The resident's code status was changed from full interventions to Do Not Resuscitate (DNR)/Do Not Intubate (DNI), but the updated consent form was not found in the paper chart. Interviews with the Charge Nurse and the Assistant Director of Nursing Services (ADNS) indicated that the form might have been sent to the hospital in error, and there was a lack of adherence to the facility's policy requiring the updated form to be placed in the resident's chart. The deficiencies in both cases highlight a failure to adhere to professional standards for maintaining complete and accessible medical records. The facility's policies on medical records and advanced directives were not followed, resulting in incomplete documentation for residents receiving hospice care and those with updated advanced directives. These lapses were identified during a review of clinical records, facility policies, and interviews with staff and family members.
Failure to Implement Enhanced Barrier Precautions and Proper Cohorting
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents who required them, particularly those with a history of Multidrug Resistant Organisms (MDROs) and those with indwelling medical devices. During a tour, it was identified that residents needing EBP were not placed under such precautions. The Infection Preventionist Nurse (RN #4) acknowledged that EBP was not currently implemented and that the facility was in the initial phase of formulating a policy and identifying residents who would need EBP. Despite knowing the implementation deadline was April 1, 2024, RN #4 faced pushback from management due to concerns about resident dignity and costs. The facility's MDRO log failed to include all necessary residents, such as Resident #55, who had a history of Clostridium difficile (C-diff) upon admission. This resident was co-horted with an individual without a C-diff diagnosis or history, which was not in line with the facility's infection control policy. RN #4 admitted to an oversight in not identifying Resident #55's C-diff history, which should have been reflected in the MDRO list. The Director of Nursing (DON) expected the infection control nurse to review such diagnoses upon admission and cohort residents accordingly. The facility's policy required maintaining a history log of residents diagnosed with infections like C-diff, MRSA, and VRE, to determine appropriate roommate assignments and monitor infection signs. However, the policy was not followed, as evidenced by the failure to log Resident #55's C-diff history. The DON confirmed that the infection control nurse should have entered this information into the history log and considered it when determining room assignments.
Failure to Revise Care Plan After Multiple Falls
Penalty
Summary
The facility failed to review and revise the care plan for a resident with a history of falls after multiple incidents of falling. The resident, diagnosed with aphasia, anxiety, and a history of falls, was identified as high risk for falls. Despite this, the care plan was not updated after falls on four separate occasions. The resident's care plan included interventions such as ensuring the call light was within reach, prompt response to requests for assistance, encouraging the resident to be in common areas for supervision, and regular toileting and checks. However, these interventions were not reviewed or revised after each fall to determine new strategies to prevent further incidents. The Director of Nursing (DON) and the Minimum Data Set Coordinator acknowledged that the care plan was not reviewed and revised after each fall. The facility's policy required the comprehensive care plan to be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly assessment, including measurable objectives and time frames to meet the resident's needs. Despite this policy, the care plan for the resident was not updated after falls on 7/24, 7/30, 8/3, and 8/8/23, leading to repeated incidents without new interventions being implemented.
Failure to Document Complete Skin Assessments
Penalty
Summary
The facility failed to document a complete assessment for Resident #1, who had potential for impairment to skin integrity. Resident #1 had diagnoses including aphasia, anxiety, and a history of falls, and was identified as high risk for falls. The admission nursing assessment noted scattered bruising on the abdomen and bilateral arms, but the clinical record lacked documentation of a complete assessment, including size, color, and exact location of the discolorations, to establish a baseline for further evaluation. Additionally, after Resident #1 sustained falls on multiple occasions, the facility failed to document complete assessments of the resulting bruises and skin tears, including a bruise to the left wrist and lower lip, and a skin tear to the left upper extremity. These assessments were necessary to monitor improvement or decline of the discolorations and were not conducted as required by the facility's policies. Furthermore, on 8/8/23, a series of puncture marks were noticed on Resident #1's right leg, but no one could provide an explanation for how these marks were acquired. The weekly evaluation of alteration in skin integrity did not document these puncture marks, and the regular nurse aide did not notice them while caring for Resident #1. The Director of Nursing was unaware of the puncture marks and stated that the Registered Nurse was responsible for completing skin assessments, including documenting the location, size, and description of any skin alterations. The facility's policies directed licensed nurses to document non-pressure skin conditions and complete weekly skin evaluations for all bruises, skin tears, and abrasions until resolved, which was not adhered to in this case.
Failure to Consistently Document Resident Monitoring
Penalty
Summary
The facility failed to consistently document the location of a resident on the resident observation sheets while on every fifteen-minute monitoring. Resident #1, who had diagnoses including aphasia, anxiety, and a history of falls, was identified as high risk for falls. Despite being placed on every fifteen-minute monitoring after a fall incident, the facility's documentation from 7/22/23 through 8/17/23 showed gaps in monitoring on multiple dates and shifts. The nurse's notes and resident observation sheets revealed that the required monitoring was not consistently documented on 8/1, 8/4, 8/5, 8/8, 8/10, 8/14, and 8/15/23 during various shifts. The Director of Nursing (DON) was unaware of these documentation lapses and confirmed that there was no policy regarding every fifteen-minute monitoring. Resident #1's care plan included several interventions to mitigate fall risks, such as ensuring the call light was within reach, prompt responses to assistance requests, encouraging the resident to be in common areas for supervision, and every two-hour toileting while awake. Despite these measures, the facility's failure to consistently document the resident's location during the fifteen-minute checks indicates a lapse in adherence to the care plan and monitoring protocols. This deficiency highlights a significant gap in the facility's ability to safeguard resident-identifiable information and maintain accurate medical records in accordance with accepted professional standards.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Davis Place | 4.2 mi | ★★★★★ | 2 | 0 |
| Colonial Health & Rehab Center Of Plainfield, Llc | 7.3 mi | ★★★★★ | 3 | 0 |
| Villa Maria Nursing And Rehabilitation Community | 7.5 mi | ★★★★★ | 4 | 0 |
| Westview Health Care Center | 7.8 mi | ★★★★★ | 3 | 0 |
| Matulaitis Rehabilitation & Skilled Care | 10.9 mi | ★★★★★ | 3 | 0 |
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