Choctaw Residential Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Choctaw, Mississippi.
- Location
- 135 Residential Center Rd, Choctaw, Mississippi 39350
- CMS Provider Number
- 255339
- Inspections on file
- 18
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Choctaw Residential Center during CMS and state inspections, most recent first.
The facility failed to protect residents from abuse when two residents with cognitive and behavioral issues inappropriately touched other residents in common areas without effective supervision. In one case, a cognitively impaired resident touched another resident’s leg and later was reported to have touched a female resident’s leg and between her thighs. In another case, a cognitively intact resident with prior documented inappropriate touching was confirmed by video to have touched a resident’s breast in a hallway. Affected residents reported the incidents to staff, but documentation was incomplete, follow-up with the victims was limited, and communication about the incidents and protective measures was insufficient, resulting in a failure to uphold residents’ rights to be free from abuse and to feel safe.
A facility failed to provide necessary behavioral health services and effective supervision to prevent inappropriate sexual contact between residents. In one case, a cognitively impaired resident with borderline intellectual functioning inappropriately touched another resident’s leg in a lobby area, and the affected resident later reported minimal follow-up and no documented assessment of the incident in her health status note. In another case, a resident with vascular dementia reported that another cognitively intact resident touched her breast in a hallway, despite prior documentation of that resident touching another resident inappropriately. In both incidents, residents were in common areas without effective supervision, and the facility did not proactively implement sufficient behavioral interventions or consistent behavioral health follow-up for the affected residents.
Several cognitively intact residents reported missing personal items, insufficient activities—especially on weekends—and excessive noise near the nurse's station, with complaints raised multiple times to staff and during council meetings. Despite these ongoing concerns, no formal grievances were filed, and the Administrator and key staff were unaware of the issues, resulting in unresolved resident complaints.
A resident with left hemiplegia and bilateral hand contractures was not provided with the care interventions outlined in their care plan, including the use of hand rolls, regular oral hygiene, and nail care. Observations and interviews confirmed that staff did not consistently follow the care plan, resulting in the resident being found with long, discolored nails, poor oral hygiene, and without prescribed contracture management devices.
Licensed nursing staff failed to follow professional standards for medication administration, resulting in two residents receiving discontinued, incorrectly scheduled, or incorrect forms of medication. In both cases, LPNs did not verify the six rights of medication administration, leading to errors such as giving a discontinued diabetes medication, administering an inhaler at the wrong time, documenting a medication that was not given, and providing the wrong form of aspirin to residents with complex medical conditions.
Three residents with intact cognition and significant medical histories reported that the facility did not provide structured group activities on weekends, offering only independent options like puzzles and coloring sheets. Staff confirmed the absence of weekend activity staff and lack of scheduled group activities, despite residents' documented preferences for such engagement.
A resident with severe hand and finger contractures, a history of cerebral infarction, and hemiplegia was repeatedly observed without the required bilateral hand rolls in place, despite care plans and therapy recommendations mandating their use every shift. Staff and therapy interviews confirmed the devices were not consistently applied, and facility policy required either application or documentation of reasons for omission.
Surveyors identified that the facility's medication error rate exceeded 5% after observing two LPNs who failed to verify the six rights of medication administration. Errors included administering a discontinued medication, giving a medication at the wrong time, documenting a medication as given when it was not, and providing the incorrect form of aspirin to two residents with complex medical conditions.
A medication cart was found unlocked and unattended in a hallway, contrary to facility policy requiring medication carts to be locked or under direct observation during medication passes. An LPN admitted to leaving the cart unlocked after being called away, and the administrator confirmed that this practice is not permitted as it could allow residents access to medications.
Surveyors found that the facility did not maintain a safe, clean, and homelike environment for several residents, including rooms with damaged walls and splintered plywood, persistent foul urine odors in a hallway and resident room despite repeated cleaning efforts, and a privacy curtain that was dirty and stained for an extended period. Staff and administrators confirmed these issues and acknowledged that they had not been resolved, impacting the comfort and safety of residents.
A resident who was totally dependent on staff for ADLs did not receive necessary oral and nail care, as evidenced by long, unclean fingernails and unbrushed teeth with visible buildup. Staff interviews confirmed the resident required total assistance and that aides were responsible for daily hygiene, but the care was not provided as observed.
Failure to Prevent and Adequately Address Resident-to-Resident Sexual Contact
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse by not preventing resident-to-resident inappropriate sexual contact and not providing effective supervision in common areas. Facility policy on Resident Rights, revised 3/24, states that each resident has the right to be free from mental and physical abuse and to have a safe, secure, and homelike environment, and that the facility is responsible for implementing interventions to prevent resident-to-resident altercations and to ensure supervision sufficient to protect residents from harm. Despite this policy, two separate incidents of non-consensual touching occurred between residents in common areas where supervision was ineffective. In the first set of incidents, one resident with borderline intellectual functioning and a BIMS score of 7, indicating severe cognitive impairment, inappropriately touched another resident with a cognitive communication deficit. On one occasion in the front lobby, the cognitively impaired resident approached the other resident and touched her leg without consent. The affected resident reported that she told him to stop and he left her alone, and she informed staff shortly after the incident. She stated that a nurse spoke with her once about what happened, but there was no further follow-up discussion or additional inquiries from other staff, and she did not receive updates on the outcome of the investigation. A later nurse’s note documented that a female resident reported this same resident inappropriately touched her twice on her leg and between her thighs, again requiring staff intervention to separate the residents. The affected resident later expressed concern that the alleged perpetrator’s name remained on the room across from hers and reported that she planned to avoid him and common areas if he returned. In the second incident, another resident with a cognitive communication deficit and a BIMS score of 13, indicating cognitive intactness, was observed and reported to have engaged in inappropriate touching of other residents. A health status note documented that this resident had previously been noted touching another resident inappropriately at the nurses’ desk and did not respond to redirection. Subsequently, a resident with vascular dementia and a BIMS score of 8, indicating moderate cognitive impairment, reported that this same resident touched her breasts without consent in the hallway in front of the nurse’s station. She immediately notified a CNA and clearly described that the resident had touched her breasts. The facility’s investigation, including review of camera footage, confirmed that the resident touched her breast while passing her in the hallway. Record review and interviews revealed that in both sets of incidents, the residents were in common areas without effective supervision at the time of the events, and although staff responded after the incidents occurred, the facility did not implement sufficient interventions to prevent the inappropriate resident-to-resident contact prior to the incidents. Interviews with the LNHA and the social worker further described gaps in the facility’s response related to the affected residents’ ongoing needs after the incidents. The LNHA acknowledged that while the facility determined that inappropriate contact had occurred and that staff responded once the incidents were reported, there were areas where the response could have been improved for the affected residents. She stated that the facility should have implemented more consistent and ongoing follow-up with the affected residents, including routine check-ins to assess fear, anxiety, or other psychosocial effects, and stronger communication with them regarding the protective measures in place. The social worker similarly acknowledged that the affected residents should have received more focused follow-up and supportive services after the allegations were made, including assessment of their immediate emotional and psychological needs, private discussions, validation of their concerns, and ensuring they felt heard. These statements, combined with the lack of documentation of the inappropriate touching in at least one resident’s health status note, demonstrate that the facility did not fully carry out its responsibility under its own Resident Rights policy to ensure residents were protected from abuse and that their concerns were adequately addressed. Record review confirmed that in both incidents, the residents were in common areas without effective supervision at the time of the events. Although staff separated residents and assessed for injuries after the incidents were reported, the facility failed to implement sufficient preventive interventions and supervision to stop the inappropriate resident-to-resident contact from occurring in the first place. The combination of ineffective supervision in common areas, repeated inappropriate touching by certain residents, incomplete documentation of the incidents in the affected residents’ records, and limited follow-up and communication with the affected residents led to the deficiency in protecting residents from abuse and ensuring their right to a safe and secure environment as required by facility policy.
Failure to Provide Necessary Behavioral Health Services and Supervision for Inappropriate Sexual Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents received necessary behavioral health care and services, specifically by not proactively assessing and implementing effective behavioral interventions to address inappropriate sexual behaviors between residents. Facility policy on Resident Rights states that each resident has the right to be free from mental and physical abuse and to have a safe, secure, and homelike environment, and that the facility is responsible for implementing interventions to prevent resident-to-resident altercations and to ensure supervision sufficient to protect residents from harm. The facility’s Behavioral Health Services policy further requires that all residents receive necessary behavioral health services to help them reach and maintain their highest level of mental and psychosocial functioning. One incident involved a resident with borderline intellectual functioning and severe cognitive impairment, who approached another resident with a cognitive communication deficit while both were seated in the front lobby and touched her leg without consent. The cognitively impaired resident had a BIMS score of 07, indicating severe cognitive impairment. The resident who was touched reported the incident to staff and stated she told him to quit and he left her alone. She later reported that she only spoke once with a nurse about what happened, that there was no further follow-up discussion or additional inquiries from other staff, and that she did not receive any updates regarding the outcome of the investigation. Her health status note for the date of the incident contained no documentation of the inappropriate touching. She also reported seeing the other resident’s name still listed on the room across from hers and stated she planned to avoid him and common areas if he returned. Record review showed that another female resident later reported that the same cognitively impaired resident inappropriately touched her twice on her leg and between her thighs. A separate incident involved a resident with vascular dementia and moderate cognitive impairment, who reported that another resident with a cognitive communication deficit and a BIMS score indicating intact cognition touched her breast without consent in the hallway in front of the nurse’s station. The resident who was touched immediately notified a CNA and clearly described that the other resident had touched her breast. Facility records showed that this same resident with intact cognition had previously been noted at the nurses’ desk touching another resident inappropriately and, when redirected, simply looked at the nurse and continued rolling in his wheelchair. In both incidents, record review revealed that the residents were in common areas without effective supervision at the time of the events. Although staff responded after the incidents occurred, the facility did not implement sufficient proactive interventions or supervision to prevent inappropriate resident-to-resident contact before these incidents took place, and affected residents did not receive consistent, documented behavioral health follow-up and support as required by facility policy.
Failure to Timely Resolve Resident Grievances Related to Missing Property, Activities, and Noise
Penalty
Summary
The facility failed to resolve resident grievances in a timely manner for four residents who participated in the resident council, specifically regarding missing clothing, insufficient activities, and excessive noise. One resident, who served as the Resident Council President and was cognitively intact, reported missing several clothing items to staff on multiple occasions. Despite the Ombudsman notifying the Case Manager about the missing items, no grievance form was completed, and the status of the missing clothing remained unresolved. The Social Services staff, responsible for completing grievances, confirmed that a grievance was not filed for this issue, and the Administrator was unaware of the situation until the day of the survey. During a resident council meeting, several residents expressed dissatisfaction with the lack of activities, particularly on weekends, and the noisy environment near the nurse's station at night. Residents reported that their concerns about limited activities and excessive noise, especially on weekends, had been raised multiple times with staff and during council meetings. One resident described being unable to sleep due to the noise, while another stated that staff were loud, played music, and gathered around the desk at night. These concerns were documented in previous council meeting minutes, but the Administrator was not aware of them, and no grievances were filed for these issues. Interviews with facility staff, including the Activity Director and Assistant Director of Nursing, revealed a lack of communication and follow-through regarding the residents' complaints. The Activity Director acknowledged the difficulty in planning activities for a diverse age group and confirmed that concerns discussed in resident council should be written up as grievances, but this was not consistently done. The Assistant Director of Nursing did not recall being informed about the noise complaints. All residents involved were cognitively intact and had voiced their concerns clearly, but the facility failed to document and address these grievances according to policy.
Failure to Implement Comprehensive Care Plan for Dependent Resident
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident who required total assistance with activities of daily living due to a history of cerebrovascular accident resulting in left hemiplegia and bilateral hand contractures. Despite the care plan specifying the use of bilateral hand rolls to prevent skin breakdown and further contracture, as well as regular oral and nail care, observations revealed that the resident was repeatedly found without hand rolls in place, had long, discolored nails (one of which was broken and hanging), and had a thick white substance on his teeth and gums. The resident reported that staff sometimes placed a hand towel in his hands instead of the prescribed hand rolls, and that oral care was not consistently provided despite his requests. Staff interviews confirmed that the care plan was not being followed, and the MDS nurse acknowledged that the purpose of the care plan was to guide staff in providing appropriate care. The resident was cognitively intact, as indicated by a BIMS score of 15, and was able to communicate his needs. The facility's own policy required the development and implementation of a comprehensive, person-centered care plan with measurable objectives and timeframes, but this was not adhered to for this resident.
Failure to Follow Professional Standards for Medication Administration
Penalty
Summary
Licensed nursing staff failed to follow professional standards of practice for medication administration, as evidenced by direct observation, record review, and staff interviews. In one instance, an LPN administered Glipizide 10 mg to a resident despite the medication having been discontinued two days prior. The same LPN also administered Albuterol Sulfate HFA inhaler at an incorrect time, as it had already been given earlier that morning, and documented the administration of Mometasone Furoate inhaler without actually giving it. The LPN did not verify the six rights of medication administration during these events. The resident involved had diagnoses including Type 2 Diabetes Mellitus and Chronic Systolic Congestive Heart Failure. In another instance, a different LPN administered Aspirin EC 81 mg to a resident without verifying the six rights of medication administration, resulting in the administration of the incorrect form of aspirin. The LPN later confirmed the error after reviewing the medication record. The resident involved had a diagnosis of End-Stage Renal Disease. In both cases, the LPNs acknowledged during interviews that they did not thoroughly check the six rights of medication administration, which contributed to the errors.
Failure to Provide Resident-Preferred Activities on Weekends
Penalty
Summary
The facility failed to provide activities that met the interests and preferences of residents, specifically for three residents who expressed a desire for structured group activities on weekends. Interviews with these residents revealed that while some activities were available during the week, there were no organized group activities on weekends, and only independent activities such as puzzles and coloring sheets were offered. Residents reported dissatisfaction with the lack of weekend activities and expressed that participating in their favorite activities was very important to them, as documented in their assessments. Staff interviews confirmed the absence of a dedicated activity staff member on weekends, with the Activity Director working only Monday through Friday. The charge nurse was responsible for assisting with independent activities on weekends, and church groups occasionally provided services, but no regular group activities were scheduled. The Administrator acknowledged the lack of structured weekend activities and stated efforts were being made to hire weekend activity staff. Activity calendars and attendance records corroborated that only independent activities were listed for weekends, and there was no documentation of resident participation in activities on those days. The residents involved had various medical diagnoses, including hemiplegia, hemiparesis following cerebral infarction, diabetes mellitus, chronic obstructive pulmonary disease, and dementia. All three residents were assessed as cognitively intact and indicated that engaging in their preferred activities was very important to them. Despite this, the facility did not provide activities tailored to their interests on weekends, resulting in unmet psychosocial needs as evidenced by resident and staff interviews, record reviews, and facility policy.
Failure to Consistently Apply Hand Rolls for Resident with Contractures
Penalty
Summary
A resident with a history of cerebral infarction and hemiplegia affecting the left nondominant side, who was cognitively intact, was observed multiple times without prescribed hand rolls in place for management of severe hand and finger contractures. The resident's care plan, as documented in the Treatment Administration Record and supported by occupational therapy recommendations, required bilateral hand rolls to be applied every shift to decrease the risk of skin breakdown and further contracture formation. Despite documentation indicating that the hand rolls were applied as ordered, direct observations on several occasions revealed that the resident did not have the hand rolls in place while in bed. Interviews with the resident, nursing staff, and the occupational therapist confirmed that the hand rolls were not consistently applied as required. The resident reported that staff sometimes placed a hand towel in his hands, but not consistently, and at the time of observation, no device was present. Nursing staff and the occupational therapist acknowledged the importance of the hand rolls and confirmed that failure to apply them could lead to worsening contractures and skin breakdown. The facility's policy stated that residents should not experience a reduction in range of motion unless clinically unavoidable, and the administrator confirmed that staff should either apply the hand rolls or document the reason for not doing so.
Medication Error Rate Exceeds 5% Due to Failure to Follow Six Rights
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a calculated error rate of 10.81% during the survey. This deficiency was identified through direct observation, record review, and staff interviews, revealing that licensed nursing staff did not consistently verify the six rights of medication administration. Specifically, one LPN administered a discontinued medication (Glipizide 10 mg) and gave an inhaler (Albuterol Sulfate HFA) at an incorrect time to a resident with Type 2 Diabetes Mellitus and Chronic Systolic Congestive Heart Failure. The same LPN also documented the administration of another inhaler (Mometasone Furoate) that was not actually given. The LPN admitted to not verifying the medication label against the medication administration record prior to administration. Another LPN was observed administering the incorrect form of aspirin (Aspirin EC 81 mg instead of the prescribed chewable tablet) to a resident with End-Stage Renal Disease. This LPN also failed to verify the six rights of medication administration by not checking the medication label against the medication record. Both LPNs acknowledged during interviews that their failure to follow proper medication administration procedures led to these errors.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
A medication cart located on C hall was observed to be unlocked and unattended during a survey, with no nurse in view. Facility policy requires that medications must be either under the direct observation of the person administering them or locked in the medication storage area or cart during a medication pass. An LPN confirmed that she had walked away from the cart and left it unlocked after being called away, acknowledging that this action allowed residents potential access to the medications. The facility administrator also confirmed that nurses are not permitted to leave medication carts unlocked and unattended, as this could allow residents to access the medications.
Failure to Maintain Safe, Clean, and Homelike Environment for Residents
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for multiple residents on one hallway, as evidenced by several direct observations and staff and resident interviews. In one instance, a resident's room had a large section of wall with missing paint and a piece of plywood with splintered, uneven edges behind the bed, which the resident expressed a desire to have repaired. The administrator confirmed that the condition of the wall and plywood could cause injury and did not meet the standard for a safe and homelike environment. Another resident's room and the adjacent hallway were noted to have an overpowering and persistent urine odor. Staff interviews revealed that the resident frequently urinated on the floor while attempting to use the toilet, and despite frequent mopping, floor replacement, and other interventions, the smell remained strong and unpleasant. Staff, including CNAs, an LPN, and the DON, acknowledged the ongoing nature of the odor problem and confirmed that it had led to complaints from other residents and family members. The administrator also confirmed awareness of the issue and that it had not been resolved, resulting in an environment that was not clean or comfortable for residents in that area. Additionally, another resident's privacy curtain was observed to be dirty and stained with large, discolored splotches. The resident stated that the curtain had not been cleaned for a long time, and both an LPN and the administrator confirmed the curtain was extremely dirty and needed cleaning. The facility's own policies required regular checking and cleaning of room curtains, but this was not followed, contributing to the failure to maintain a homelike environment.
Failure to Provide Required Oral and Nail Care for Dependent Resident
Penalty
Summary
A resident who was totally dependent on staff for personal hygiene, due to medical diagnoses including cerebral infarction and hemiplegia affecting the left nondominant side, did not receive necessary oral and nail care. Observations revealed the resident had fingernails approximately one inch long with a brown substance on each nail, and one nail was broken and hanging inside the palm. The resident's upper and lower teeth and lower gum line were covered in a thick white substance. The resident was observed in this condition on multiple occasions, and reported having previously asked staff to brush his teeth. Interviews with staff confirmed that the resident required total assistance for personal hygiene and that aides were responsible for daily oral care. A registered nurse acknowledged the potential for skin breakdown due to the resident's contracted fingers and confirmed the need for nail trimming. The administrator stated that staff were expected to perform and document these care tasks. Documentation confirmed the resident's total dependence on staff for ADLs, but the required care was not provided as observed.
Latest citations in Mississippi
A resident with hemiplegia, hemiparesis, and cognitive impairment had a care plan directing staff to apply and remove a right ankle splint at specific times each day and to provide passive stretching to prevent decline in ROM. Observation found the splint not in use and lying on a chair, and the resident was unsure when it was last applied. A PTA reported the resident had developed foot drop and that the splint could no longer be applied without additional therapy, attributing this to the splint not being used daily as ordered. The DON confirmed that staff failed to follow the established care plan for splint application and ROM management.
A resident with hemiplegia and hemiparesis after a cerebral infarction, and severe cognitive impairment (BIMS 5), had physician and therapy orders for right-hand and right-ankle splinting with passive ROM to manage contractures and maintain ROM. Surveyors observed a foot splint lying unused and the resident’s right hand contracted into a fist without a hand roll. The resident could not recall when the foot splint was last applied and reported never having a hand roll. An LPN was unaware of the need for the splint and confirmed no hand roll was in use. Records showed the hand splint order was discontinued at the responsible party’s request due to pain, but OT was not notified and no alternative such as a hand roll was initiated. PT had documented improved ankle ROM and recommended a PODUS boot, while a PTA later reported the resident had developed foot drop related to the ankle splint not being applied as ordered. The DON confirmed that daily ankle splint orders existed and that the hand splint was discontinued without alternative interventions to prevent contracture.
The facility failed to protect resident narcotic medications from misappropriation when an LPN handed over a medication cart’s narcotic keys to an RN without performing required narcotic counts before and after the transfer, and the cart was later found unlocked in the nurses’ station. During the subsequent shift change count, staff discovered multiple missing doses of oxycodone-acetaminophen and hydrocodone-acetaminophen prescribed PRN for pain to four residents with conditions including dementia, COPD, dysphagia, and diabetic neuropathy. Review of individual controlled drug logs showed corrected balances to account for the missing tablets, confirming that controlled substances were unaccounted for during the period of unsecured cart access and improper key control.
Two ambulatory residents with dementia, severe cognitive deficits, and known wandering behavior, each wearing a wander guard bracelet, were able to exit through a unit door when a visitor held it open, despite the door alarm sounding and prior observations that they frequently walked together and approached doors. An LPN responded to the alarm and, along with other staff, initiated a search when the residents could not be found on the unit; staff ultimately located the residents across a four-lane highway and returned them to the building without injury. The incident occurred despite facility policies requiring use of a security system for residents unable to protect themselves from harm by wandering, and staff and leadership acknowledged that the residents had a history of walking the halls together and going to doors, and that increased monitoring and restricting visitor access to door codes could have prevented the elopement.
A cognitively impaired resident with dementia, agitation, and a history of wandering was previously assessed by the IDT as not being at risk for elopement and did not have elopement precautions in place. On one occasion, a visitor exited through the front door without realizing the resident followed outside, and staff later discovered the resident alone on the front porch after being missing for several minutes. An LPN and CNA participated in locating and returning the resident, and the incident revealed that supervision and elopement risk assessment were insufficient for this resident.
A resident with Type 2 DM and moderately impaired cognition had two unstageable heel DTIs documented on the MDS and physician orders for treatment to both heels, but the comprehensive care plan did not include any problem, goals, or interventions related to these pressure injuries. LPNs responsible for MDS and care plan completion acknowledged the omission and stated that although they periodically audit by comparing orders to the care plan, this situation was missed. The DON reported she expected the wound care nurse to update the care plan with new wound treatment orders, while an RN stated she could update interventions but had not been trained to create a new focused care plan and was unaware it was her responsibility to add the DTI treatment orders to the care plan.
A controlled substance prescribed for a cognitively intact resident with a left femur fracture was delivered and signed for by an LPN but was not entered on the narcotic accountability record or narcotic box package count and was later found to be missing. One LPN reported receiving the blister pack of thirty Hydrocodone/Acetaminophen 10-325 mg tablets from another LPN, placing it on the nurses’ station, and leaving the area, while both LPNs stated they were in the medication room as the medication remained unattended. The DON and Administrator confirmed that staff failed to secure the controlled medication as required by facility policy and that the missing tablets could not be located.
Surveyors found that staff failed to properly secure and store medications for two residents. For one resident, an LPN received a delivery of Hydrocodone-Acetaminophen, passed it to another LPN, and the controlled medication was left unattended at the nurses’ station instead of being immediately locked and entered into the narcotic count, after which it could not be located. For another resident, two bottles of Lorazepam oral concentrate, documented on the narcotic record and labeled to be protected from light and refrigerated, were observed stored in a locked medication cart rather than in the designated medication refrigerator, even though staff acknowledged knowing the manufacturer’s refrigeration requirement.
A resident with hemiplegia and hemiparesis following cerebral infarction was transferred by facility van to a psychiatric hospital for evaluation and was later determined by the facility to be discharged due to aggressive behavior and threats, with staff stating they could not meet the resident’s needs. The Administrator and Social Services Director communicated with the psychiatric facility and the resident’s family about finding alternative placement and informed the family the resident would not be allowed to return, but no formal involuntary discharge notice or written appeal rights were provided, and no physician discharge order was documented, contrary to facility policies requiring a completed transfer form and written notice of transfer/discharge with appeal information.
The facility did not adequately investigate, address, or resolve repeated grievances about food quality and temperature raised through Resident Council meetings. Over several months, residents reported that weekend meals were bad, food was consistently cold, beverages lacked sufficient ice, and breakfast items were hard or unpalatable. While limited steps such as using temperature-holding containers, sending trays out faster, and in-servicing dietary staff were noted, there was no documented monitoring, follow-up, or evaluation of effectiveness. Cognitively intact residents continued to report cold, poor-tasting food, and staff, including the Dietary Manager and Social Services, acknowledged awareness of the complaints without evidence of thorough follow-up or resolution.
Failure to Implement Care Plan for Ankle Splint and ROM Management
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan for contracture management and splinting to prevent decline in range of motion for one resident. The facility’s policy on prevention of decline in range of motion required that, based on the comprehensive assessment, the facility provide interventions, exercises, and/or therapy to maintain or improve ROM. The resident’s care plan, initiated on 8/1/25, identified an ADL self-care performance deficit related to stroke, hemiplegia, and immobility, placing the resident at risk for functional decline. The care plan interventions directed staff to apply a splint to the right ankle after breakfast, provide passive stretch to the right ankle after applying the splint, remove the splint at lunchtime, reapply the splint after supper with passive stretch, and remove the splint at bedtime. On observation, the resident’s ankle splint was not in use and was found lying in a chair in the resident’s room, and the resident was unsure when the splint was last applied. The PTA reported that the resident had developed foot drop and that the ankle splint could no longer be placed without additional therapy, confirming this was related to the splint not being applied daily as ordered. The DON stated that the care plan was used to inform staff how to care for the resident and verified that staff failed to follow the care plan when they did not apply the ankle splint. Record review showed the resident was admitted with hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, and an MDS assessment indicated a BIMS score of 5, reflecting cognitive impairment at the time of the deficiency.
Failure to Implement ROM and Splinting Orders Resulting in Contractures and Foot Drop
Penalty
Summary
The facility failed to provide ordered range of motion (ROM) and splinting interventions to prevent decline in ROM for a resident with hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side. The resident was admitted with these diagnoses and had physician orders and therapy recommendations for contracture management and splinting. An OT evaluation documented decreased ROM in the right upper extremity and recommended a resting hand splint and a restorative splint and brace program, with a subsequent OT evaluation recommending continuation of the contracture management and splinting program. A physician order directed staff to apply a right-hand splint after breakfast, provide passive stretch to the right elbow, wrist, and hand once daily, and remove the splint before dinner. Another physician order required application of a right ankle splint after breakfast and after supper with passive stretching following application. The facility’s own policy stated that residents without limited ROM should not experience a reduction in ROM unless clinically unavoidable. During observation, surveyors noted a foot splint lying unused in the resident’s chair and the resident’s right hand contracted into a fist without a hand roll in place. The resident reported not knowing when the foot splint was last applied and stated she had never had a hand roll. An LPN stated she did not know why the splint was in the room, believed the resident was not required to wear it, and confirmed the resident did not have a hand roll. Record review showed the right-hand splint order was discontinued at the responsible party’s request due to pain, but the OT reported she had not been notified of this discontinuation and stated a hand roll should have been initiated when the splint was stopped; she further stated the resident’s hand was now contracted into a fist. A PT discharge summary documented improved right ankle ROM with therapy and recommended a PODUS boot daily for up to five hours, while a PTA later reported the resident had developed foot drop and that the ankle splint could no longer be applied without additional therapy, confirming this was related to the splint not being applied daily as ordered. The DON verified that there were physician orders for daily ankle splinting and acknowledged that the right-hand splint was discontinued without alternative interventions to prevent contracture. The resident’s MDS showed a BIMS score of 5, indicating severe cognitive impairment.
Failure to Secure Narcotic Medications and Maintain Key Control
Penalty
Summary
The deficiency involves the facility’s failure to protect resident medications from misappropriation on one of four medication carts, resulting in missing controlled substances for four residents. The facility’s abuse, neglect, and exploitation policy defines misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings or money without the resident’s consent. On a specific date, during the 7:00 PM shift change narcotic count, staff identified that multiple doses of Percocet and Norco (hydrocodone-acetaminophen) were missing from the narcotic box on a single medication cart. Prior to this discovery, the assigned LPN had confirmed that the narcotic count was correct earlier in the day. The events leading to the deficiency included the LPN giving her medication cart narcotic keys to an RN while she left the area to perform a urine specimen collection. The LPN did not complete a narcotic count before or after transferring the keys, which was not in accordance with facility expectations for key control and chain of custody. When the LPN returned, she observed the medication cart in the nurses’ station and unlocked. The RN later confirmed that she had moved the cart into the nurses’ station but denied administering any medications during the time she had possession of the keys. During the subsequent 7:00 PM narcotic count, discrepancies were identified, and a search of the cart and nurses’ station did not locate the missing medications. Record review showed that four residents’ controlled medication logs required corrections to reflect missing tablets. One resident with dementia had an order for oxycodone-acetaminophen 5-325 mg every 12 hours as needed for pain; the narcotic log initially showed a remaining balance of 20 tablets after a documented administration, but was later corrected to 16 tablets to account for four missing tablets. A second resident with COPD had an order for oxycodone-acetaminophen 10-325 mg every eight hours as needed; the log was corrected from a remaining balance of five tablets to four, indicating one missing tablet. A third resident with dysphagia had an order for hydrocodone-acetaminophen 5-325 mg every 24 hours as needed; the log showed two tablets on hand after the resident returned from pass with no administrations documented, and was later corrected to zero, indicating two missing tablets. A fourth resident with type 2 diabetes mellitus with diabetic neuropathy had an order for hydrocodone-acetaminophen 7.5-325 mg every six hours as needed; the log was corrected from a remaining balance of eight tablets to seven, indicating one missing tablet. These discrepancies, combined with the unsecured cart and improper key transfer without counts, led to the determination that resident medications were not protected from misappropriation.
Failure to Prevent Elopement of Two Cognitively Impaired Wanderers
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent elopement for two residents with known wandering and elopement risk. Both residents were ambulatory, frequently walked throughout the facility together, and were known to staff as wanderers. Each resident had a diagnosis of dementia with severe cognitive deficits documented on their MDS assessments, and both had Wander/elopement alarms (wander guard bracelets) in place and used daily. The facility’s elopement/wandering policy stated that residents who are incapable of adequately protecting themselves and unable to determine when they are at risk for harm by wandering out of the facility should be placed on the resident security system to ensure safety. On the day of the incident, video surveillance later reviewed by the Administrator showed that a visitor entered an exit door on the B Unit at approximately 6:20 PM. The two residents at risk for elopement approached the door, and the visitor held the door open, allowing them to walk out of the building. The residents were wearing wander guard bracelets, and when they exited, the door alarm sounded. A nurse responded immediately to the alarm, exited the facility, and went down the walkway but did not see the residents. Staff were then alerted that the residents were missing, and a facility-wide search was initiated. Staff interviews and the facility’s documentation confirmed that the residents had previously been observed walking together throughout the facility and approaching doors, including the exit door involved in the incident. The Administrator reported that review of the video showed the two residents had approached the same door together two or three times prior to the elopement event. Despite their known patterns of wandering, severe cognitive impairment, and prior door-approach behavior, the residents were able to exit the facility unnoticed and unsupervised when the visitor held the door open. Staff ultimately located the residents across a four-lane high-capacity highway approximately 528 feet from the exit door and returned them to the facility, where body audits and assessments documented no injuries and intermittent confusion. The State Agency determined that the facility’s failure to provide adequate supervision to prevent the elopement of these residents, who had exhibited exit-seeking behaviors, placed them and other residents at risk for wandering and elopement in a situation likely to cause serious injury, harm, impairment, or death and cited the facility at F689 with Immediate Jeopardy and Substandard Quality of Care. The residents’ medical records and elopement reports documented that both were confused, had impaired memory, and were identified as wanderers. One resident had a BIMS score of 3 and the other a BIMS score of 0, both indicating severe cognitive deficits. Progress notes and elopement reports recorded that staff were notified when the residents were not on the unit and could not be located, that all staff were engaged in searching, and that the residents were ultimately found outside and assisted back into the building. Interviews with CNAs and an LPN described hearing a Code W called, running outside, and seeing the residents across the street after they had crossed the four-lane highway. The DON acknowledged that the residents were always walking in the facility, often together, and that they had wandered to doors and looked out, and agreed that increased monitoring and not allowing visitors to have door codes could have prevented the residents from leaving the building.
Removal Plan
- Conducted a facility search.
- Notified police of missing residents.
- Director of Nursing interviewed staff and residents.
- Notified the Medical Director and residents’ families.
- Administrator and Director of Nursing checked the wander guard system and facility doors to ensure proper functioning.
- Returned Resident #1 and Resident #2 to the facility.
- Completed an incident report.
- Completed an emergency Quality Assurance meeting.
- Initiated in-service training for all staff on the elopement policy, including a quiz to validate comprehension, and required staff (including contract staff) to complete the in-service before working their next scheduled shift, with Administrator monitoring compliance.
- Responded immediately to the door alarm by sending staff outside to locate residents and notifying additional staff to assist with the search.
- Reviewed video surveillance and confirmed a visitor held the door open allowing residents to exit.
- Held an emergency Quality Assurance meeting with the Medical Director, Director of Nursing, Administrator, Regional Director, involved staff, and Infection Preventionist.
- Changed the main entry door code.
- Verified entrance door signage was in place instructing not to allow residents to exit unaccompanied.
- Identified residents at risk for elopement and ensured elopement bracelets/transmitters were functional and doors were locking appropriately.
- Reviewed care plans for residents at risk for elopement.
- Completed body audits on Resident #1 and Resident #2.
- Conducted audits verifying resident location, elopement risk, and wander guard bracelet function.
- Medical Records updated care profiles of residents at risk for wandering.
- Assistant Administrator began audits of all doors for function and security.
- Provided in-services on elopement policy and procedure, Resident Rights, and incident and accident reporting.
- Conducted elopement drills on each shift.
- Implemented monitoring systems to sustain compliance.
- Director of Nursing to monitor wander guard system checks three times weekly for four weeks or until substantial compliance is attained.
- Director of Nursing to monitor resident behavior for elopement attempts via incident reports, observations, and communications weekly for four weeks or until substantial compliance is attained.
- Quality Assurance Committee to meet for four weeks to review compliance with the plan of action, then continue routine Quality Assurance monitoring if no further concerns are noted.
- Administrator to hold follow-up Quality Assurance meetings monthly for two months then quarterly thereafter to ensure sustained compliance.
- Updated entry screening kiosk to include an additional reminder and attestation to ensure resident safety, requiring visitors to agree that no resident comes in or out with them and triggering a staff alert if the visitor refuses.
- Administration spoke directly with the visitor to confirm visitor policies and procedures.
Elopement of Cognitively Impaired Resident Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent a cognitively impaired resident with a history of wandering from exiting the building unattended. The resident had diagnoses including dementia with agitation and a BIMS score of three, indicating severe cognitive impairment. The resident had been readmitted from a geriatric psychiatric hospitalization and was known by the DON to have a history of wandering. Despite this, the interdisciplinary team had previously determined that the resident was not at risk for elopement, and no elopement interventions such as a wander guard were in place at the time of the incident. On the day of the event, a visitor observed the resident standing near the front door and exited the facility without realizing the resident followed him outside. Staff later became aware that the resident was missing, and an LPN assisted in locating the resident. A CNA ultimately found the resident outside on the front porch and returned the resident to the facility, with the investigation determining the resident had been outside unattended for approximately five minutes. Staff interviews confirmed that the resident ambulated in the halls and had not previously attempted to exit the building, and that the resident was only reassessed and provided with a wander guard after the incident.
Failure to Care Plan for Pressure Injuries and Treatment Orders
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident with pressure injuries. The facility’s undated Care Plan Policy and Procedure stated that each resident’s care plan would remain current and inform staff of needs, strengths, goals, and approaches, and that a comprehensive person-centered care plan would be completed as needed. Record review showed that the resident was admitted with Type 2 Diabetes Mellitus with ketoacidosis without coma and, per the Discharge MDS with an ARD of 1/19/26, had a BIMS score of 12 indicating moderately impaired cognition. Section M of the MDS documented two unstageable pressure injuries presenting as deep tissue injuries (DTIs). Physician orders dated 12/10/25 directed treatment to right and left DTI pressure ulcers. Despite these documented DTIs and treatment orders, review of the resident’s comprehensive care plan revealed no care plan addressing the DTIs on the left and right heels, which was inconsistent with the physician orders. During interviews, two LPNs responsible for MDS and care plan completion confirmed that the care plan did not include the DTIs and stated that care plans are developed based on the MDS and physician orders, and that audits comparing orders to care plans are done periodically but this had been missed. The DON stated her expectation that the wound care nurse update the care plan with new wound care treatment orders. An RN reported she could update care plan interventions but had not been trained to develop a new focused care plan and had not added the physician’s DTI treatment orders to the care plan, and she was not aware it was her responsibility to do so.
Unsecured Controlled Medication Left Unattended and Lost
Penalty
Summary
The facility failed to prevent misappropriation of resident property when a controlled substance prescribed for a resident was left unattended and subsequently went missing. Facility policies on abuse and neglect defined misappropriation of resident property to include missing prescription medications or diversion of resident medications, including controlled substances, and the Medication-Controlled Substances policy required that only authorized licensed nursing and pharmacy personnel have access to controlled medications, that all controlled substances be stored in a locked cabinet or compartment, and that accurate accountability of all controlled drugs be maintained. Despite these policies, a pharmacy courier delivered thirty Hydrocodone/Acetaminophen 10-325 mg tablets for a resident with a left femur fracture, and the medication was signed for by an LPN but was not signed onto the narcotic accountability record, was not documented on the narcotic box package count, and could not be located. The resident, who was cognitively intact with a BIMS score of 15 and had a physician’s order for Hydrocodone/Acetaminophen, was later informed that the tablets delivered had been lost. Interviews revealed that one LPN received the blister pack of thirty Hydrocodone/Acetaminophen tablets from another LPN and placed it on the nurses’ station before leaving the area, leaving the controlled medication unattended. Both LPNs reported being in the medication room while the medication remained unattended at the nurses’ station. The DON reported being notified that the medication was missing and that an investigation confirmed the medication could not be located and had been left unattended, and the Administrator confirmed staff failed to ensure controlled medications were secured and accessible only to authorized personnel and that the facility was unable to determine the location of the missing medication.
Failure to Secure Controlled Drugs and Follow Refrigerated Storage Requirements
Penalty
Summary
The deficiency involves the facility’s failure to store and secure medications, including controlled substances, in accordance with professional standards and manufacturer instructions. For Resident #1, who was admitted with a left femur fracture and was cognitively intact with a BIMS score of 15, the physician ordered Hydrocodone-Acetaminophen 10-325 mg tablets. A facility investigation documented that a pharmacy courier delivered 30 tablets of this controlled medication, which were received and signed for by an LPN but were never documented in the narcotic count system and were later unable to be located. One LPN reported that after receiving the Hydrocodone-Acetaminophen from another LPN, she left the medication unattended at the nurses’ station while she completed other tasks instead of immediately securing it in the locked medication cart. The LPN who initially received the medication from the courier confirmed that the controlled medication had not been immediately secured in the locked cart following delivery. For Resident #3, who was admitted with heart disease and had a BIMS score of 10 indicating moderately impaired cognition, the physician ordered Lorazepam (Ativan) oral concentrate. The narcotic record showed that two containers of Lorazepam were signed into the narcotic record on the date of admission. Manufacturer prescribing information for the Lorazepam oral concentrate specified that it must be protected from light and stored refrigerated at 36–46°F. During a controlled drug count, surveyors observed that two bottles of Lorazepam oral concentrate for this resident were stored in the locked medication cart rather than in a refrigerator, despite the label instructions requiring refrigeration. One LPN confirmed the manufacturer’s storage instructions on the label but was unsure why the medication had not been refrigerated, and another LPN acknowledged awareness that the medication required refrigeration but confirmed it had been stored in the medication cart instead of the designated medication refrigerator.
Failure to Provide Required Involuntary Discharge Notice and Appeal Rights
Penalty
Summary
The deficiency involves the facility’s failure to provide required written notice of an involuntary discharge, including appeal rights, and to obtain a physician’s discharge order before refusing readmission of a resident following a hospital transfer. Facility policy titled “Transfer Form” stated that it is the policy of the facility to provide a completed and accurate transfer form to residents transferred or discharged from the facility, and the policy titled “Appealing a Transfer or Discharge Notice” stated that residents have the right to appeal transfer or discharge notices and, upon notice of transfer or discharge, will be provided with a statement of their right to appeal. Record review showed that the resident, admitted with hemiplegia and hemiparesis following cerebral infarction, left the facility by facility van to be admitted to a psychiatric hospital for evaluation. Progress notes dated several days after the transfer documented that the resident had been discharged from the facility due to aggressive behavior and that, per conversation with the psychiatric hospital, the Administrator and Social Services Director would assist in finding alternative placement and home health if needed. Documentation further indicated that, due to threats made, the facility stated it was unable to meet the resident’s needs and communicated with the resident’s family that the resident would not be allowed to return. During interview, the Administrator confirmed that neither the resident nor the family was provided a formal involuntary discharge notice or information on appeal rights and that no physician order for discharge could be located, acknowledging that the formal notice, appeal rights, and physician order should have been obtained prior to discharge.
Failure to Investigate and Resolve Ongoing Food-Related Grievances
Penalty
Summary
The facility failed to ensure that grievances voiced through the Resident Council regarding food quality and temperature were thoroughly investigated, addressed, and resolved. Resident Council minutes over multiple months documented repeated complaints that weekend food was "bad," tasted sweet, and that food was cold by the time it reached residents. Additional concerns included insufficient ice in water and tea, hard breakfast biscuits and toast, and cold grits. Although the facility’s grievance policy stated that residents and families could voice grievances without reprisal and that the facility would make prompt efforts to resolve grievances, there was no documentation that the initial complaint about weekend food quality was addressed, and subsequent complaints continued without evidence of thorough investigation or resolution. Resident Council Department Response Forms showed limited actions, such as placing food in containers to maintain temperature, conducting an in‑service for dietary staff, sending food out faster, and instructing staff to pass trays promptly, but there was no documentation of monitoring, follow‑up, or evaluation of whether these measures were effective. Residents interviewed, all cognitively intact per their MDS BIMS scores, consistently reported that the food remained cold and did not taste good, with one resident noting that staff would reheat food only if requested. The Dietary Manager acknowledged awareness of the complaints and stated he had spoken with weekend staff and made changes like replacing tray carts and providing guidance on food preparation, but confirmed there was no documentation of ongoing monitoring or additional interventions. Social Services and the Administrator both acknowledged awareness of the complaints and that additional follow‑up and resolution efforts should have occurred, yet no evidence of such follow‑up was present in the records.
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