Comfort Care Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Laurel, Mississippi.
- Location
- 1100 West Drive, Laurel, Mississippi 39440
- CMS Provider Number
- 255352
- Inspections on file
- 6
- Latest survey
- November 18, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Comfort Care Nursing Center during CMS and state inspections, most recent first.
Surveyors identified multiple deficiencies in food storage and handling, including undated and unlabeled prepared foods, exposed and spoiled produce, and improper handling of ready-to-eat foods by staff using gloved hands. Dry goods were left uncovered, and items requiring refrigeration were improperly stored. Staff and administration acknowledged these lapses in food safety and sanitation protocols.
The facility did not promptly review or resolve repeated resident grievances about inadequate housekeeping, particularly on weekends when no dedicated staff were assigned. Multiple residents reported ongoing issues with unclean rooms and unemptied trash, and these concerns were documented over several months without effective response from management, despite their awareness of the problem.
Staff did not report allegations of verbal abuse by an LPN towards two residents, despite multiple accounts describing the nurse's behavior as loud and demeaning. Additionally, multiple reports of stolen resident funds were not reported to the State Agency, with the Administrator stating a lack of awareness of the reporting requirement. These actions were not in accordance with facility policy, which mandates immediate reporting of such incidents.
Two residents, both cognitively intact and with significant medical histories, reported being treated in a demeaning, intimidating, and disrespectful manner by an LPN, including raised voices, sarcastic remarks, and rough tones during medication administration. Staff interviews confirmed the LPN also used vulgar language and insults toward coworkers, contributing to an environment lacking in dignity and respect for both residents and staff.
Two cognitively intact residents reported that an LPN spoke to them in a loud, demeaning, and intimidating manner, with one resident feeling degraded and afraid after a medication-related interaction. Another resident described the LPN as using a rough tone and intimidating residents. Staff interviews confirmed the LPN's negative, vulgar, and insulting behavior towards both residents and staff, including the use of profane language. The facility's policy prohibits abuse, but these incidents demonstrate a failure to prevent verbal abuse.
Multiple residents reported theft of personal funds, with amounts ranging from $15 to over $100, from their rooms or belongings. Despite notifying the Resident Council President and various staff, including the Administrator, DON, and Social Service Director, residents did not receive updates or reimbursement. The Social Service Director confirmed forwarding statements to the Administrator but was unaware of any investigation outcomes. The Administrator acknowledged the reports but did not reimburse residents, citing uncertainty about the exact amounts. Residents affected had varying cognitive abilities and medical conditions, and the facility did not follow its policy to protect resident property.
A wound care cart containing medications such as Nystatin, Santyl, and Dakin's solution was left unlocked and unattended for fifteen minutes, with wound cleanser unsecured on top. An RN later returned to secure the cart. Both the RN and DON confirmed that the cart should have been locked at all times when not in use, in accordance with facility policy.
A third-party LCSW provided psychosocial therapy to multiple residents without informing facility staff, the physician, or resident representatives, as required by facility policy. The LCSW accepted self-referrals from cognitively intact residents and did not disclose service recipients, resulting in a lack of physician orders and no notification to responsible parties for the initiation of therapy.
The facility did not develop or implement care plans that included psychosocial therapy services provided by an LCSW for residents receiving such therapy. Staff confirmed that no documentation or care plan interventions reflected these services, as the LCSW, a third-party provider, refused to share resident information due to confidentiality. This resulted in a lack of coordination and individualized interventions for residents receiving therapy for depression or major depressive disorder.
The facility did not obtain physician orders for psychosocial therapy services provided by a third-party LCSW, resulting in therapy being delivered without appropriate physician oversight or documentation. Multiple residents received cognitive behavioral therapy for depression or related conditions, but there were no physician orders, referrals, or care plans in place, and the LCSW did not share session information with facility staff.
A Licensed Clinical Social Worker provided cognitive behavioral therapy to multiple residents without physician oversight, formal referral, or interdisciplinary coordination. The LCSW accepted self-referrals from cognitively intact residents and did not communicate with facility staff or medical personnel, resulting in a lack of psychosocial assessments, care planning, and monitoring for those receiving therapy.
A Licensed Clinical Social Worker provided individual psychosocial therapy to multiple residents but kept all therapy documentation separate from the facility's medical record system, resulting in incomplete and inaccessible records. Facility staff were unaware of which residents were receiving therapy or the details of the services, as the LCSW did not share any documentation, leaving the interdisciplinary team without access to pertinent clinical information.
The facility failed to submit accurate PBJ staffing data to CMS for December 2023, resulting in a report of no RN hours and less than 24 hours/day licensed nursing coverage for multiple days. The error was due to an interface issue, and staff were unaware of the inaccuracy.
Deficient Food Storage, Labeling, and Handling Practices Observed in Kitchen
Penalty
Summary
Surveyors observed multiple failures in food storage and handling practices during two kitchen inspections. In Refrigerator #1, several trays of prepared salads, bowls of pudding, fruit, and staff food were found without date labels, and some items were in direct contact with each other. Additional items, such as blueberry cobbler, fruit cocktail, and prefilled whipped topping, were also missing required labeling or were past their use-by dates. In Refrigerator #3, raw chicken tenders were left exposed with the lid off, cheese slices were left open and dried out, and produce such as strawberries and oranges were found to be spoiled or overly ripe. Dry storage bins for sugar, rice, and cornmeal were left uncovered, and an opened bag of grits was not securely closed. The Food Service Supervisor acknowledged these deficiencies and stated that it was his responsibility to ensure food safety. Further observations revealed unsanitary handling of ready-to-eat foods by kitchen staff. Staff members were seen using gloved hands to pick up and move bread and noodles directly on residents' plates, contrary to food safety protocols. An opened bottle of lemon juice requiring refrigeration was found improperly stored on a shelf. Interviews with staff confirmed awareness of proper food handling procedures, but lapses were attributed to forgetfulness. The Administrator acknowledged the issues with food storage, labeling, and unsanitary handling, emphasizing that all kitchen staff are responsible for maintaining food quality and sanitation.
Failure to Timely Address Resident Grievances Regarding Housekeeping
Penalty
Summary
The facility failed to review and resolve multiple resident grievances regarding housekeeping in a timely and effective manner, as evidenced by ongoing complaints documented in three consecutive months of Resident Council meeting minutes. Residents repeatedly expressed concerns about unclean floors, unemptied trash, and a lack of general housekeeping, particularly on weekends when no dedicated housekeeping staff were assigned. These grievances were raised during council meetings but did not receive a response or resolution from facility management. Specific residents reported that their rooms were left unclean throughout the weekend, with one resident managing persistent odors and unclean conditions due to accidents until staff returned on Monday. Interviews with the Housekeeping Manager and Administrator confirmed awareness of the complaints and acknowledged that staffing shortages, especially on weekends, contributed to the unresolved issues. Despite being aware of the ongoing concerns, the facility did not take prompt or effective action to address the grievances, resulting in persistent environmental issues for the residents.
Failure to Report Allegations of Verbal Abuse and Misappropriation of Resident Property
Penalty
Summary
The facility failed to ensure timely reporting of allegations of verbal abuse and misappropriation of resident property as required by federal regulations and its own policies. Specifically, staff did not report allegations of verbal abuse involving two residents, despite both the residents and a witness describing the LPN's behavior as loud, demeaning, and intimidating. The LPN admitted to speaking loudly, and a CNA corroborated the negative and vulgar conduct. The incident was not reported to the Director of Nursing, and the DON confirmed she was unaware of the situation, stating that staff are required to report such allegations and that the nurse would have been removed from resident care pending investigation if reported. Additionally, the facility failed to report multiple allegations of theft of resident funds involving five residents to the State Agency. The Administrator acknowledged that several residents had reported missing money but stated that reimbursement was not provided due to lack of verification of the amounts lost. The Administrator also admitted to not knowing that such incidents needed to be reported to the State Agency. The facility's policy requires immediate reporting of abuse and misappropriation allegations to appropriate authorities, but this protocol was not followed in these cases.
Failure to Ensure Residents' Right to Dignity and Respect by Nursing Staff
Penalty
Summary
Licensed nursing staff failed to treat residents with dignity and respect, as evidenced by multiple reports from both residents and staff. One resident reported that a night shift LPN raised her voice, spoke in a demeaning and intimidating tone, and argued with her about taking a newly prescribed medication that was causing stomach upset. The resident described feeling talked down to, afraid, degraded, and intimidated. The resident's roommate confirmed the LPN's loud and intimidating behavior, describing the interaction as uncalled for and rude. Another resident, who is a former CNA, also reported that the same nurse spoke to residents in a rough tone, used her authority to intimidate, and treated them like children, which she deemed inappropriate for the setting. Staff interviews further corroborated these concerns. A CNA reported that the LPN had spoken to her in a demeaning and vulgar manner, including the use of profanity and insults, leading the CNA to avoid working with the nurse. The facility scheduler confirmed that the CNA, who rarely complains, reported being verbally abused by the LPN during a night shift. Both the Administrator and the DON acknowledged that all residents have the right to be treated with dignity and respect. The residents involved were cognitively intact, as indicated by their BIMS scores, and had medical histories including hemiplegia, hemiparesis following cerebral infarction, and acute on chronic systolic congestive heart failure.
Failure to Protect Residents from Verbal Abuse by Staff
Penalty
Summary
The facility failed to protect residents from verbal abuse by staff, as evidenced by multiple interviews and record reviews involving two cognitively intact residents. One resident reported that a night shift LPN raised her voice, spoke in a demeaning and intimidating manner, and responded sarcastically when questioned about a new medication, making the resident feel degraded, afraid, and intimidated. The resident's roommate confirmed the LPN's loud and intimidating behavior, and another resident described the nurse as using a rough tone, talking down to residents, and using her authority to intimidate. Both residents expressed that the nurse's conduct was inappropriate and made them feel uncomfortable and fearful. Staff interviews corroborated the residents' accounts, with a CNA reporting that the same LPN was extremely negative, loud, vulgar, and insulting to both staff and residents during the shift in question. The CNA recalled the LPN using profane language towards staff and described her as intimidating. The facility scheduler confirmed that the CNA, who rarely complains, reported verbal abuse by the LPN, including cursing and name-calling. The Director of Nursing stated she had not been informed of the incident but noted a second, unrelated complaint about the same LPN's verbal abuse towards staff on the same night. The facility's policy prohibits abuse, neglect, and exploitation, but the events described indicate a failure to implement these protections.
Failure to Protect Residents from Misappropriation of Funds
Penalty
Summary
The facility failed to protect residents from misappropriation of their funds and did not implement corrective action or reimburse residents after multiple reports of missing money. Several residents reported to the Resident Council President and staff that their personal funds, ranging from $15 to over $100, were stolen from their rooms or personal belongings. Despite these reports, residents did not receive updates on the status of their complaints or any reimbursement for their losses. The facility's policy requires protection of resident property, but this was not followed in these cases. Interviews with residents revealed that they had reported the thefts to various staff members, including the Administrator, DON, Social Service Director, and security personnel. However, the residents consistently stated that no follow-up or resolution was provided. The Social Service Director confirmed that she collected statements and forwarded them to the Administrator, but was unaware of any investigation outcomes or reimbursements. The Administrator acknowledged the reports of stolen money but stated that, in his view, the facility was not obliged to reimburse residents unless the exact amounts could be confirmed. The affected residents had varying degrees of cognitive function, with some being cognitively intact and others having moderate impairment. Their medical histories included conditions such as heart disease, heart failure, anxiety disorder, anemia, and hemiplegia. The lack of action and communication from the facility left residents feeling unsafe, discouraged, and financially vulnerable, as their reports of missing funds were not addressed or resolved.
Unattended and Unlocked Wound Care Cart with Medications
Penalty
Summary
The facility failed to ensure that medications and biologicals were securely stored to prevent unauthorized access. On one of the survey days, a wound care cart located in the 200 Hall was observed to be unlocked and unattended for fifteen minutes, with wound cleanser left unsecured on top of the cart. The cart contained medications such as Nystatin, Santyl, Dakin's solution, and other wound care agents. The cart was only locked after a registered nurse returned, placed the unsecured cleanser inside, and secured the cart. Interviews with the registered nurse and the Director of Nursing confirmed that the cart should have been locked at all times when not in use, as per facility policy. The nurse explained that the keypad locking mechanism was malfunctioning, requiring manual locking, and admitted to forgetting to lock the cart after use. The Director of Nursing and the Administrator both acknowledged the expectation that all treatment carts remain locked and that no medications or supplies should be left unsecured.
Failure to Notify Physician and Resident Representative of Initiation of Psychosocial Therapy
Penalty
Summary
The facility failed to notify the physician and the resident representative (RR) when individual psychosocial therapy services were initiated for three sampled residents, with the potential to affect all 21 residents receiving such therapy. According to the facility's policy, notification of the resident, consultation with the physician, and notification of the RR are required when there are changes in treatment or services. However, a Licensed Certified Social Worker (LCSW) from a third-party provider delivered psychosocial therapy to residents without informing facility staff, the physician, or the RRs. The LCSW stated that all referrals were self-initiated by cognitively intact residents and did not share information about which residents were receiving services, citing confidentiality. Interviews with facility staff, including the Social Services staff member, Registered Nurse, Nurse Practitioner, and the physician, confirmed that they were unaware of which residents were receiving therapy from the LCSW. As a result, no physician orders were obtained, and no notifications were made to the RRs regarding the initiation of therapy. The Administrator acknowledged that the facility did not follow its own policy for physician and RR notification for residents receiving psychosocial services from the LCSW. Record reviews for the three sampled residents showed that each had a BIMS score indicating they were cognitively intact and had no documented behaviors or mood symptoms at the time of assessment. Documentation from the LCSW confirmed that these residents received Cognitive Behavioral Therapy for depression on multiple occasions, but there was no evidence in the medical records that the physician or RRs were notified about the initiation or continuation of these services.
Failure to Include LCSW Psychosocial Therapy in Resident Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed the psychosocial needs of residents receiving individual therapy from a Licensed Clinical Social Worker (LCSW). Specifically, the care plans for three sampled residents did not include the ongoing psychosocial therapy services provided by the LCSW, nor did they reflect coordination of care, consistent monitoring, or individualized interventions based on the residents' psychosocial needs. This omission was identified through record reviews, interviews with facility staff, and review of facility policy, which requires that all identified needs, including mental and psychosocial, be addressed in the care plan with measurable objectives and timeframes. Interviews with facility staff, including the Social Services Director, RN, LPN/MDS Coordinator, and ADON, confirmed that there were no behavioral care plan interventions or documentation related to the LCSW's services. The LCSW, who is a third-party provider and not employed by the facility, refused to share information about the residents she served, citing confidentiality. As a result, the facility was not informed of the therapy sessions, and no physician's orders or documentation were provided to support the inclusion of these services in the residents' care plans. The interdisciplinary team was not involved in developing or reviewing care plans related to these psychosocial therapy services. Record reviews for the three residents showed that each had received cognitive behavioral therapy from the LCSW for depression or major depressive disorder, with therapy provided on a regular basis. Despite this, their medical records and care plans did not reflect these services or any related interventions. The lack of documentation and care planning for these services affected not only the three sampled residents but also had the potential to impact all 21 residents who received psychosocial therapy from the LCSW.
Failure to Obtain Physician Orders for Third-Party Psychosocial Therapy Services
Penalty
Summary
The facility failed to ensure that psychosocial therapy services provided by a third-party Licensed Clinical Social Worker (LCSW) were delivered and documented according to professional standards. Specifically, the LCSW provided ongoing behavioral therapy to residents without obtaining physician's orders, and the facility did not have records of referrals, care plans, or notifications to resident representatives for these services. Interviews with facility staff, including the Social Services Director, RN, Assistant Director of Nursing, and the physician, confirmed that no physician's orders or referrals were in place for the residents receiving these services. The LCSW also did not share resident names or session documentation with the facility, citing confidentiality, and the facility's policy required physician's orders for all services provided to residents. Record reviews for three sampled residents revealed that each had received multiple sessions of cognitive behavioral therapy from the LCSW for conditions such as major depressive disorder and depression, despite having no documented behaviors or mood symptoms on their Minimum Data Set (MDS) assessments. The medical records for these residents did not contain any physician's orders reflecting the behavioral therapy they received. The deficiency was identified as having the potential to affect all 21 residents who received psychosocial therapy from the LCSW.
Failure to Coordinate and Oversee Behavioral Health Services Provided by External LCSW
Penalty
Summary
The facility failed to identify, assess, and coordinate behavioral health services for three residents who were receiving individual psychosocial therapy from a Licensed Clinical Social Worker (LCSW). The LCSW, employed by a local hospital's behavioral health program, provided ongoing cognitive behavioral therapy to residents within the facility without physician oversight, formal referral, or interdisciplinary coordination. The LCSW accepted self-referred residents, regardless of whether a clinical need had been identified, and did not communicate with facility staff, the nurse practitioner, or the physician regarding which residents were receiving services. Interviews with facility staff, including the Social Services Director, RN, ADON, Administrator, NP, and Physician, confirmed that there was no communication or coordination regarding the therapy services being provided. The facility was unable to conduct appropriate psychosocial assessments, implement monitoring interventions, or evaluate the effectiveness or necessity of the therapy. The LCSW stated that, due to confidentiality, she did not inform facility staff or medical personnel of the residents receiving therapy, and all referrals were self-initiated by cognitively intact residents. Record reviews showed that the LCSW provided therapy to 21 residents, including the three sampled residents, none of whom exhibited behaviors or mood symptoms according to their MDS assessments. There were no physician orders, care plans, or notifications to resident representatives regarding the therapy services. The lack of oversight and coordination resulted in the facility being unaware of the therapy being provided, with no monitoring or follow-up for changes in residents' psychosocial or behavioral health status.
Failure to Integrate Psychosocial Therapy Documentation into Medical Records
Penalty
Summary
The facility failed to maintain complete and readily accessible medical records for all residents receiving individual psychosocial therapy. Specifically, a Licensed Clinical Social Worker (LCSW) provided therapy to approximately 21 residents but kept all therapy documentation in a locked cabinet, separate from the facility's medical record system. The LCSW did not share progress notes or any documentation with the facility, citing confidentiality, which resulted in incomplete medical records for residents receiving these services. Facility staff, including the Social Services Director, RN, and Assistant Director of Nursing, confirmed that they did not have access to information about which residents were receiving therapy or the details of the services provided. Record reviews for three sampled residents revealed that while the LCSW documented therapy sessions and treatment plans, this information was not integrated into the facility's records. The sampled residents had various diagnoses, including fibromyalgia, sacral spina bifida, and hemiplegia, and were cognitively intact according to their MDS assessments. Despite receiving regular cognitive behavioral therapy for depression or major depressive disorder, there was no documentation of these services in the facility's medical record system, leaving the records incomplete and inaccessible to the interdisciplinary team.
Failure to Submit Accurate PBJ Staffing Data
Penalty
Summary
The facility failed to electronically submit accurate direct care staffing information based on payroll data to CMS for December 2023. A review of the Payroll Based Journal (PBJ) Staffing Data report revealed that the facility had triggered for four or more days within the quarter with no RN hours and four or more days within the quarter with less than 24 hours/day licensed nursing coverage from December 2, 2023, to December 31, 2023. The facility's policy on Nurse Staffing Information, revised in November 2023, did not address the accurate submission of PBJ data. The Business Office Coordinator, responsible for entering the PBJ data, stated she was unaware of the failure and did not receive any error messages or warnings after submission. The Director of Nursing (DON) also confirmed that she was not aware of any errors and stated that the facility always had adequate nursing staff and 24-hour RN coverage during the period in question. The Administrator confirmed that there was an interface error that resulted in the staffing data not being collected for the specified period. Despite the facility having adequate nursing staff and RN coverage, the data was not submitted accurately to CMS. The Administrator acknowledged that it was ultimately the facility's responsibility to ensure the accuracy of the submitted information, even though no feedback or alerts were received indicating an error. The deficiency was identified through staff interviews and record reviews, highlighting a lapse in the facility's data submission process.
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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