Diversicare Of Eupora
Inspection history, citations, penalties and survey trends for this long-term care facility in Eupora, Mississippi.
- Location
- 156 E Walnut Ave, Eupora, Mississippi 39744
- CMS Provider Number
- 255117
- Inspections on file
- 20
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Diversicare Of Eupora during CMS and state inspections, most recent first.
An LPN repeatedly documented PRN opioid pain medications for multiple residents at identical, preset times during routine med passes, rather than based on individualized pain assessment and actual administration times. One cognitively intact resident with a history of stroke consistently denied pain and stated he did not take pain medication, while other staff confirmed he did not request analgesics; however, the LPN documented frequent Norco administration and high pain scores for him, and later admitted giving medication without his consent and falsely recording pain levels. Review of MARs and narcotic logs for 13 residents showed large clusters of PRN Norco and oxycodone entries at the same times across different rooms, and the LPN acknowledged that the records did not accurately reflect real administration times and that she sometimes entered pain scores without asking residents, contrary to facility policy and professional standards.
Two cognitively intact residents experienced undignified care when staff failed to provide timely toileting assistance and used disrespectful communication. One resident, with multiple chronic conditions, reported that a CNA questioned her need to use the bathroom at night and later left her sitting on the toilet for about 30 minutes until she used the bathroom call light, after which the CNA stated she had to make her rounds. Another resident with cerebral palsy, incontinent and fully dependent on staff for toileting and hygiene, was found by a family member with the call light sounding, wet, and with three soiled, spaghetti-covered towels left on her chest from lunch; when a CNA entered, she removed the towels and told the resident she was "just showing out" because her sister was present. The DON and nursing staff interviews confirmed expectations that residents be treated with dignity and respect and receive timely toileting.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Staff failed to immediately report an incident where an LPN used profanity and applied force to a resident. Two CNAs who witnessed the event delayed reporting, assuming others had done so, and another LPN did not recognize the behavior as abuse. The incident was reported to the State Agency but not to the Board of Nursing, contrary to policy, despite staff having received recent training on abuse reporting.
A resident with insulin-dependent diabetes and a diabetic foot ulcer was admitted without orders for insulin or wound care, despite repeatedly informing staff that her insulin had been discontinued in error and requesting provider notification. Nursing staff did not obtain clarification or new orders for insulin or wound care, and the resident self-administered insulin without assessment or documentation. Wound care was delayed and not documented until several days after admission, contrary to facility policy requiring prompt intervention and physician notification.
The facility failed to resolve grievances related to food quality and bed linen changes for several residents. Despite repeated complaints in resident council meetings, issues such as lack of food variety, poor taste, and infrequent linen changes were not addressed. The Administrator and Dietary Manager were aware of the complaints but did not document or follow up effectively, leading to ongoing resident dissatisfaction.
The facility failed to provide palatable, attractive, and appropriately heated meals to residents, leading to dissatisfaction among several residents. Complaints included cold, flavorless, and improperly cooked food, with limited meal options that did not meet dietary needs. Despite raising these issues with the Dietary Manager, the concerns remained unaddressed.
A resident with an overactive bladder and other medical conditions was denied assistance with toileting due to staff being occupied with meal tray distribution. Staff interviews revealed a misunderstanding of policy, believing they could not assist residents during mealtimes due to cross-contamination concerns. The DON acknowledged the resident's right to use the bathroom but needed to review the policy.
The facility failed to implement and develop care plans for three residents, resulting in deficiencies in their care. A resident's nail care was neglected, another resident did not have a care plan for necessary leg brace use due to communication failures, and a third resident lacked a care plan for Binge Eating Disorder after readmission. Staff interviews confirmed these oversights.
A resident with diabetes and moderate cognitive impairment did not receive necessary nail care, resulting in long nails that caused self-scratching. Facility staff acknowledged that diabetic nail care was not scheduled or documented, although it was expected to be performed as needed.
A facility failed to monitor a resident with a new diagnosis of Binge Eating Disorder. Despite the resident's frequent requests for snacks and taking food from carts, staff were unaware of the diagnosis. The Medication Administration Record lacked monitoring for this behavior, focusing on other issues. The DON confirmed the absence of monitoring, noting its importance for managing the resident's condition.
A facility failed to implement dietary recommendations for a resident receiving enteral nutrition via PEG tube. The RD's recommendations to adjust tube feeding and water flushes were not acted upon due to a communication lapse. The DON did not notice the recommendations in the email, and the LPN did not act on them without instruction. Consequently, the resident's nutritional needs were not met.
The facility inaccurately completed Section N of the MDS for two residents, leading to incorrect documentation of anticoagulant and antibiotic medications. One resident was documented as receiving anticoagulants but was on antiplatelet medication, while another was documented as receiving anticoagulants but was on antibiotics. These errors were confirmed by the MDS Coordinator and attributed to a remote MDS worker.
A resident with limited mobility did not receive necessary services to maintain or improve mobility due to staff failing to apply leg braces as per the therapy plan. The resident's therapy was discontinued, and the facility did not enter the order for brace application into the system, resulting in no tasks for staff to follow. Miscommunication and misunderstanding of the agreed schedule led to the resident not wearing the braces, impacting his mobility improvement efforts.
A resident's inhalant medication was left unsecured at the bedside by an LPN after administration, contrary to the facility's policy requiring medications to be stored in a locked compartment. The resident, who has COPD and Asthma, was assessed for supervised medication administration. The DON confirmed the risk posed by the unsecured medication.
The facility failed to provide bedtime snacks to residents, including those with diabetes, as snacks were left at the nurse's desk and not distributed. Mobile residents could retrieve snacks, but those who were not mobile were left without. Staff interviews confirmed the issue, with the Administrator unaware and the Dietary Manager stating that aides were responsible for distribution.
Clustered False Documentation and Non-Individualized PRN Opioid Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure licensed nursing staff followed professional standards of practice for accurate, individualized assessment and documentation of PRN opioid pain medications for 13 residents on one medication cart. Facility policies required medications to be administered as prescribed, in accordance with good nursing principles, and clinical records to be complete and accurate for continuity of care, including consistent evaluation, management, and documentation of pain. Despite these requirements, record review of January and February 2026 MARs and controlled substance records showed repetitive, clustered documentation of PRN narcotic administration at identical times for multiple residents, which did not reflect individualized assessment or real-time documentation. One resident reported concerns that an LPN attempted to administer medications without allowing her to visually verify them, that she questioned whether her Norco was present, and that she did not experience expected pain relief; on one occasion she observed a pill that did not resemble her usual Norco and was told it was broken. Resident #9 was a cognitively intact resident with hemiplegia and hemiparesis following cerebral infarction, whose MDS indicated frequent pain affecting sleep and daily activities. However, during interviews he consistently denied pain, stated he did not take pain medication, and reported refusing pain medication when offered. Other LPNs confirmed that he did not usually take pain medication and had never reported pain or requested PRN analgesics from them. In contrast, MARs and the controlled substance inventory showed that one LPN (LPN #3) documented Norco administration to this resident at highly consistent times (around 7:01 AM, 12:31 PM, and 6:31–6:49 PM) and recorded pain scores of 8–9 on her shifts, while other shifts documented pain scores of zero. LPN #3 later admitted she did not ask this resident about pain, administered medication without his consent, and falsely documented high pain scores. Across all 13 residents with PRN opioid orders (primarily Norco and one resident with oxycodone), MAR review revealed a pattern of clustered documentation by LPN #3, with large groups of residents recorded as receiving PRN pain medication at the exact same times on multiple dates. In January and February, PRN doses were repeatedly documented at standardized times such as 7:01 AM, 11:01 AM, 12:31 PM, 3:01 PM, and clustered evening times between 6:31 PM and 6:49 PM, sometimes for as many as 12 residents at once. LPN #3 acknowledged in a telephone interview that she administered all PRN pain medications during routine med passes and intentionally selected one set time for all residents so they could receive subsequent doses based on order frequency, and that the medical records did not accurately reflect actual administration times. She further admitted she did not always ask residents about their pain, sometimes entered pain levels without asking them, and recognized that this practice and her documentation were not in accordance with nursing standards. The DON confirmed that review of the 13 residents’ MARs showed a pattern of documentation inconsistencies related to this nurse, and the nurse had a history of prior medication documentation and narcotic handling issues identified through progressive discipline and consultant pharmacist review.
Failure to Provide Dignified, Timely Toileting and Respectful Care
Penalty
Summary
The deficiency involves failure to ensure residents were treated with dignity and respect by providing timely toileting assistance and by using respectful communication. One resident, cognitively intact and dependent on staff for assistance, reported that around 11:00 PM she activated her call light to request help to the bathroom. CNA #1 responded by questioning whether someone had already taken her to the bathroom and, after being informed the resident had been asleep and needed to go at that time, did assist her. Later, at approximately 3:00 AM, the same resident again required toileting assistance. Although CNA #1 assisted her to the toilet, the resident stated she was left sitting there for about 30 minutes without supervision. When CNA #1 did not return, the resident activated the bathroom call light, and upon returning, CNA #1 told her, "I told you I was coming back. I had to make my rounds." The resident reported telling CNA #1 she could not sit on the toilet for that length of time and should not have to remain there for an extended period, and further reported she notified the night nurse, who said the issue would be reported to RN #2. RN #2 later stated she was not made aware of any complaints or concerns about this resident on Monday morning. The DON acknowledged CNA #1 could be gruff in tone, had multiple prior write-ups, including for leaving a resident on the toilet longer than appropriate, and confirmed the expectation that residents receive timely toileting. A second cognitively intact resident with cerebral palsy, always incontinent of bladder, frequently incontinent of bowel, and dependent on staff for toileting and personal hygiene, was also involved. A family member reported arriving shortly after 1:00 PM and finding the resident’s call light sounding because she was wet and needed to be changed, with three soiled towels from lunch, covered in spaghetti, left on her chest. The family member stated the call light had been going off for some time before day-shift CNA #5 entered the room, removed the soiled towels, and said to the resident, "You're just showing out because your sister is here." CNA #5 later confirmed that dirty towels had been left on the resident’s chest and that the family was upset, and stated she left the room to allow time for the situation to deescalate. The DON confirmed her expectation that all residents have the right to be treated with dignity and respect.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Immediately Report and Recognize Abuse Allegations Involving Licensed Staff
Penalty
Summary
The facility failed to ensure that all allegations of abuse were immediately reported to the State Agency and the appropriate licensing board, as required by facility policy and regulations. Specifically, an incident involving a licensed nurse using profanity and applying force to a resident was witnessed by two CNAs, but both delayed reporting the incident until the following day, assuming another staff member had already reported it. Additionally, another LPN who overheard the use of profanity did not consider it abuse and did not report the incident. The incident was eventually reported to the State Agency, but not to the Board of Nursing, as the facility did not substantiate the abuse despite having statements from both CNAs. Interviews with staff confirmed a lack of immediate reporting and a failure to recognize the incident as abuse. The Administrator and DON acknowledged that staff did not follow the policy requiring immediate reporting of abuse allegations and that the required notification to the Board of Nursing was not made. Record review showed that all involved staff had attended a recent in-service training on abuse and neglect, which emphasized the importance of immediate reporting of any suspicion of abuse.
Failure to Provide Resident-Centered Care and Timely Physician Notification for Insulin and Wound Care
Penalty
Summary
The facility failed to identify and provide needed care and services that were resident-centered and in accordance with the resident's preferences, goals for care, and professional standards of practice for one resident. Upon admission, the resident, who had a history of insulin-dependent diabetes mellitus and a diabetic ulcer, informed staff that her insulin had been discontinued in error at the hospital and requested that the provider be contacted to clarify and reinstate her insulin orders. Despite repeated requests from the resident over several days, the nursing staff did not contact the provider for clarification or obtain new orders for insulin or wound care. The resident continued to self-administer her own insulin using a personal insulin pen, without an assessment for self-administration, and without facility orders or documentation for this medication. Additionally, the resident had a diabetic ulcer on her toe that was covered with a dressing upon admission. She requested wound care and dressing changes, but was told there were no orders for wound care. Although the dressing was changed by nurses on two occasions, the resident was unsure of the treatment used, and there was no documentation of wound care orders or treatments until several days after admission. The RN Treatment Nurse did not assess the wound until several days after admission, at which point a new wound care order was obtained from the Nurse Practitioner. Documentation revealed that the facility's policy required immediate implementation of resident-specific interventions and prompt notification of the physician when an open area was identified, which was not followed in this case. Interviews with facility staff, including the DON and RN Treatment Nurse, confirmed that the resident's requests for insulin and wound care were not addressed in a timely manner, and that appropriate notifications to providers were not made. The DON acknowledged that the resident had the right to necessary treatments and medications, and that the facility failed to obtain orders for both wound care and insulin, resulting in a lack of appropriate treatment and care according to the resident's needs and preferences.
Unresolved Grievances on Food Quality and Linen Changes
Penalty
Summary
The facility failed to adequately address grievances related to food quality and bed linen changes for several residents. Despite the facility's policy to actively seek resolution and keep residents informed, grievances from five residents regarding food concerns and infrequent linen changes were not resolved. Interviews with residents and staff revealed ongoing dissatisfaction with the food, including lack of variety, poor taste, and inadequate vegetarian options. Residents reported these issues repeatedly in resident council meetings, but no effective action was taken to address their concerns. The facility's Administrator and Dietary Manager were aware of the food complaints, yet failed to document or follow up on the grievances. The Administrator acknowledged the residents' dissatisfaction but did not complete a formal grievance process. The Dietary Manager claimed to have addressed the concerns but lacked documentation to support this. Additionally, the Social Services staff did not complete grievances for food complaints, believing them to be outside their responsibility. Residents also expressed concerns about the infrequency of bed linen changes, which were reportedly only done every two weeks or during deep cleaning. Despite these issues being raised in resident council meetings, there was no documentation or evidence of corrective actions taken. The facility's failure to resolve these grievances highlights a lack of effective communication and follow-up on resident concerns, leading to ongoing dissatisfaction among the residents.
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and served at a safe and appetizing temperature for seven of the twelve residents sampled. Residents reported issues such as food being cold, lacking flavor, and not being cooked thoroughly. For instance, one resident mentioned receiving cornbread that was too hard to chew, while another resident complained about the lack of gravy on rice, which was a personal preference that was not accommodated despite discussions with the Dietary Manager. Several residents expressed dissatisfaction with the quality and variety of meals provided. One resident, who is diabetic, noted that the meal options were not suitable for their dietary needs, as they included multiple starchy items. Another resident, who is a vegetarian, reported a lack of appropriate meal options and described the food as disgusting and lacking seasoning. Additionally, there were instances where residents received incorrect meal items, such as being served a chicken salad sandwich instead of the requested tuna salad. Observations by the State Agency confirmed the residents' complaints, noting that sample trays from the kitchen contained food that was not warm and lacked flavor. The Dietary Manager acknowledged receiving complaints from residents about the food quality and confirmed that there were ongoing concerns. Despite these issues being raised in resident council meetings and directly with the Dietary Manager, the problems persisted, indicating a failure to address the residents' dietary needs and preferences adequately.
Failure to Assist Resident with Toileting During Mealtime
Penalty
Summary
The facility failed to honor a resident's right to a dignified existence and self-determination when a staff member refused to assist a resident with toileting. On one of the survey days, a resident expressed an urgent need to use the bathroom after returning from an appointment. Despite using the call light to request assistance, the resident was informed by a Registered Nurse (RN) that assistance could not be provided because staff were occupied with passing meal trays. The RN and the Director of Nursing (DON) did not return to assist the resident, leaving the resident in distress. Interviews with staff, including the DON and Certified Nurse Aides (CNAs), revealed a misunderstanding of facility policy, with staff believing they were not allowed to assist residents with toileting during mealtimes due to concerns about cross-contamination. The DON acknowledged the resident's right to use the bathroom when needed but indicated a need to review the policy. The resident involved was cognitively intact, with medical diagnoses including overactive bladder, Type 2 Diabetes Mellitus, and heart failure.
Failure to Implement and Develop Care Plans for Residents
Penalty
Summary
The facility failed to implement and develop care plans for three residents, leading to deficiencies in their care. Resident #41's care plan included daily nail care, but observations revealed that the resident's fingernails were long and untrimmed, indicating that the care plan was not followed. Interviews with staff confirmed the oversight. Resident #51 required leg braces to aid mobility, but no care plan was developed for their use. The resident reported not wearing the braces since therapy ended, and staff interviews revealed a communication failure in entering therapy orders into the system, resulting in the absence of a care plan. Resident #113, who was diagnosed with Binge Eating Disorder, did not have a care plan addressing this condition. The oversight was confirmed during interviews with the RN Director of Clinical Services and the DON, who acknowledged that the diagnosis was not incorporated into the care plan upon the resident's readmission. This lack of a care plan for behavior monitoring was attributed to a failure in updating the resident's care needs after hospital discharge.
Failure to Provide Diabetic Nail Care
Penalty
Summary
The facility failed to provide adequate personal hygiene care for a resident, specifically in the area of nail care. The resident, who is diabetic and moderately cognitively impaired, expressed the need for her nails to be cut as they were long and causing her to scratch herself. During an observation and interview, it was noted that the resident's nails were approximately one-half inch in length, indicating they had not been trimmed in a significant amount of time. Interviews with facility staff, including an LPN and the DON, revealed that diabetic nail care was not scheduled or documented in the Treatment Administration Record (TAR) but was expected to be performed as needed. The LPN confirmed that nail care for diabetic residents should be conducted by a nurse due to the potential for skin injury. Despite this understanding, the facility did not have a formal process in place to ensure regular nail care for diabetic residents, leading to the oversight in the resident's personal hygiene.
Failure to Monitor Binge Eating Disorder in Resident
Penalty
Summary
The facility failed to provide appropriate behavioral monitoring and interventions for a resident with a new diagnosis of Binge Eating Disorder. The resident, who was admitted with Type 2 Diabetes and Schizophrenia, was readmitted with the additional diagnosis of Binge Eating Disorder. Despite this, the facility did not implement monitoring for this behavior. Interviews with staff, including CNAs and an RN, revealed that they were unaware of the resident's Binge Eating Disorder diagnosis, although they noted the resident's frequent requests for snacks and instances of taking food from carts. The Medication Administration Record did not include monitoring for Binge Eating Disorder, focusing instead on other behaviors such as hallucinations and delusions. The Director of Clinical Services and the DON confirmed the absence of monitoring for the disorder, acknowledging that the diagnosis was not picked up upon the resident's return from the hospital. The DON noted that behavior monitoring is crucial for timely management, especially given the resident's severe cognitive impairment and the potential impact on blood sugar levels due to binge eating.
Failure to Implement Dietary Recommendations for Enteral Nutrition
Penalty
Summary
The facility failed to address dietary recommendations for a resident receiving enteral nutrition through a PEG tube. The Registered Dietician (RD) assessed the resident and recommended changes to the tube feeding and water flushes to meet the resident's nutritional needs. The RD sent these recommendations to the interdisciplinary team via email. However, the Director of Nursing (DON) did not notice the recommendations in the email, and the Licensed Practical Nurse (LPN) did not act on them as she was not instructed to do so by the DON. Consequently, the necessary changes to the resident's nutritional plan were not implemented. The resident, who was admitted with diagnoses including cerebral infarction and gastrostomy care, continued to receive inadequate nutrition as per the existing orders. The RD's recommendations, which included increasing the caloric intake and adjusting the water flushes, were not communicated to the supervising physician for approval and activation in the electronic medical record. This oversight resulted in the resident's nutritional needs not being met during their stay at the facility.
Inaccurate MDS Medication Coding for Two Residents
Penalty
Summary
The facility failed to accurately complete Section N of the Minimum Data Set (MDS) assessment for two residents, leading to discrepancies in medication documentation. For Resident #46, the MDS indicated that the resident received anticoagulant medication for seven days during the observation look-back period. However, a review of the Electronic Medication Administration Record (eMAR) revealed that the resident did not receive any anticoagulant medication during this period. Instead, the resident was on antiplatelet medication, which was incorrectly coded by a remote MDS worker. The resident was admitted with diagnoses including Peripheral Vascular Disease, Tachycardia, and Atherosclerotic heart disease. Similarly, for Resident #96, the MDS inaccurately documented that the resident received anticoagulant medication for seven days, while the eMAR showed no such medication was administered. Instead, the resident was on an antibiotic, Macrobid, which was not coded in the MDS. The resident's admission diagnoses included Cerebral infarction and Hyperlipidemia. The MDS Coordinator confirmed these coding errors during an interview, attributing them to a remote MDS worker's mistake.
Failure to Apply Leg Braces for Resident with Limited Mobility
Penalty
Summary
The facility failed to ensure a resident with limited mobility received appropriate services and assistance to maintain or improve mobility. The resident, who was supposed to wear leg braces twice a day to improve mobility, reported that staff had not applied the braces since his therapy was discontinued. The braces were observed to be unused in the resident's room, and interviews confirmed that the staff had not followed through with the plan of care established by the therapy team. The Physical Therapist confirmed that the resident's therapy was discontinued, and a plan was in place for the resident to continue using the braces. However, the Director of Nursing (DON) was unaware of the issue and noted that there was no active order for the braces in the system. The failure to enter the order into the system resulted in no tasks being assigned to staff, leading to the resident not receiving the necessary range of motion services. Interviews with staff revealed a lack of communication and understanding of the agreed-upon schedule for brace application. A Certified Nursing Assistant (CNA) reported that the resident refused to wear the braces when offered at an incorrect time, which was not aligned with the resident's preferences. The Physical Therapy Assistant confirmed that the facility staff did not apply the braces as required, and the resident expressed gratitude for the resolution of the issue, hoping the new system would prevent future occurrences.
Improper Storage of Inhalant Medication
Penalty
Summary
The facility failed to store an inhalant medication in a locked storage compartment, as observed during a medication administration for a resident. The incident involved a respiratory inhaler, which was left on the resident's overbed table by an LPN after administration. The resident confirmed that the nurse had brought the inhaler for use earlier and left it at the bedside. The LPN admitted to forgetting to return the inhaler to the locked medication cart, despite being aware of the facility's policy on medication storage. The resident involved had a history of Chronic Obstructive Pulmonary Disease and Asthma and was cognitively intact, as indicated by a BIMS score of 15. The resident was assessed for medication administration with supervision, not independent administration. The Director of Nursing confirmed that the improper storage of medication posed a risk for unauthorized access. The facility's records showed an active order for the inhaler, which was administered by the LPN on the day of the observation.
Failure to Provide Bedtime Snacks to Residents
Penalty
Summary
The facility failed to provide residents with a bedtime snack, as revealed during a resident council meeting. Six residents, including those with diabetes, reported not receiving snacks at night. The facility's snack program indicated that snacks were delivered to the nurse's desk between 7:30 pm and 8:00 pm, but they were not distributed to residents. Instead, residents who were mobile could retrieve snacks from the desk, leaving those who were not mobile without access. This practice resulted in a 'first come, first served' situation, disadvantaging residents who could not reach the desk. Interviews with staff, including the Administrator and Dietary Manager, confirmed the issue. The Administrator was unaware of the problem and noted that the kitchen had stopped sending individual snacks with residents' names. The Dietary Manager stated that bulk snacks were sent to the nurse's desk, and aides were responsible for distribution. A Registered Nurse working the night shift confirmed that residents often had to ask for snacks at the desk. The report highlights the facility's failure to ensure that all residents, particularly those with diabetes, received necessary bedtime snacks to prevent low blood sugar levels.
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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