Edgewood Health & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Byram, Mississippi.
- Location
- 205 Byram Parkway, Byram, Mississippi 39272
- CMS Provider Number
- 255103
- Inspections on file
- 26
- Latest survey
- March 2, 2026
- Citations (last 12 mo.)
- 9 (4 serious)
Citation history
Health deficiencies cited at Edgewood Health & Rehabilitation during CMS and state inspections, most recent first.
A resident with dementia and recent right femur fracture, requiring wheelchair use and one-person assist for stand-pivot transfers, was subjected to verbally abusive, demeaning, and intimidating treatment by two CNAs during care, while repeatedly requesting help and complaining of pain. Two additional CNAs were present for part of the interaction, heard staff telling the resident to get up and that she was not handicapped, observed an unsuccessful attempt to stand, and left without reporting the incident. The resident’s representative later reported the abuse with an audio recording capturing the resident crying, screaming, complaining of rough treatment, and begging staff to stop while staff mocked and laughed. RNs, the DON, and a lead CNA who reviewed the recording described the language and tone as cruel, degrading, and malicious, yet the allegation was not reported to the SA within required timeframes, no immediate investigation occurred, and facility administration did not promptly implement protective measures, leading to an Immediate Jeopardy finding under F600.
A facility failed to report an allegation of verbal abuse involving a resident to the State Agency within the required 2-hour timeframe. A resident’s representative reported the alleged verbal abuse, supported by an audio recording, to RNs and requested to speak with administration. The RN supervisor promptly notified the DON, who then notified the Administrator, but the allegation was not reported to the State Agency until two days later, well beyond policy and regulatory requirements. Interviews with the DON, Administrator, RN supervisor, and the resident’s representative confirmed the internal notification times and the delayed external reporting, resulting in a deficiency for failure to timely report alleged violations.
A resident’s representative reported an allegation of verbal abuse, supported by an audio recording of staff cursing at the resident while the resident screamed. An RN supervisor promptly notified the DON and the Administrator, and staff who heard the recording considered the interaction abusive, but no immediate interviews of staff or other residents were conducted, no comprehensive resident assessments were documented, and protective interventions were not implemented beyond moving the resident to another unit. The DON did not come on-site until the following day, when only a single interview with the resident was completed, and contact with the representative and broader staff and resident interviews did not occur until two days after the initial report, during which time staff alleged to be involved continued providing care. The facility’s actions did not follow its abuse policy requiring prompt investigation, suspension of suspected staff, and protection of residents, leading surveyors to cite Immediate Jeopardy for failure to investigate alleged violations under 42 CFR 483.12(c)(2).
Facility administration failed to timely report an allegation of verbal abuse supported by an audio recording, did not immediately remove the alleged CNA perpetrator from resident contact, and delayed initiating an investigation. A resident’s representative reported the incident to nursing staff, who notified the DON and Administrator, but the allegation was not reported to the State Agency within required timeframes, and no staff interviews were conducted the day the allegation was received. The only immediate action taken was moving the resident to another unit at the family’s request, while the alleged CNA continued working until later termination, despite an existing abuse policy and an Administrator job description requiring compliance with reporting and investigative requirements.
Two residents who were dependent for bed mobility and required q2h repositioning did not receive timely turning and repositioning assistance in accordance with facility policy and standards of care. One resident with a history of stroke, dysphagia, and severely impaired cognition remained on her back for approximately five hours despite being care-planned for q2h turns, with the assigned CNA confirming only one repositioning earlier in the morning. Another alert and oriented resident with CHF and cervical spondylosis reported not being turned since early morning, and the CNA acknowledged that the first repositioning of the day occurred late in the morning and that she was unaware of any earlier turns. The RN Supervisor, who had responsibility for both residents during the morning, stated he had not checked on one resident and was unaware of the missed repositioning, describing the delay in care as a communication issue, while facility leadership stated their expectation that staff provide q2h and PRN repositioning to prevent discomfort and skin integrity damage.
A deficiency was cited when surveyors found that medications on one medication cart were not stored and labeled correctly, including Restasis eye drop vials placed inside an Albuterol nebulizer solution package labeled for a resident. The facility’s storage policy did not address placing one medication inside another’s packaging. A resident with a history of stroke, dysphagia, and severely impaired cognition had a family representative who observed a nurse enter the room to give a nebulizer treatment using a vial that was clearly not the correct medication, and the error was identified before administration.
A resident dependent on staff for mobility and transfers due to quadriplegia was injured during a transfer when a CNA attempted to use a mechanical lift without the required assistance of a second staff member and failed to lock the Geri-recliner or open the lift base. This resulted in the resident falling and sustaining a rib fracture, despite clear care plan instructions and staff training on proper transfer procedures.
Two residents experienced preventable accidents due to staff failing to follow established safety protocols. In one case, a dependent resident was transferred using a mechanical lift by only one CNA, resulting in a fall and rib fracture. In another case, a resident's wheelchair tipped over in a facility van during transport because staff had not received proper training on the securement system. Both incidents involved residents with significant physical or cognitive impairments and were confirmed by staff interviews and documentation.
A resident with severe cognitive impairment was transported in a facility van by two CNAs who had not received formal training or competency checkoff on the van's securement system. During the trip, the resident's wheelchair tipped over backwards onto the van floor. The CNAs assisted the resident, who was not injured, back to an upright position. Review of facility policy and staff files confirmed a lack of documented training or competency verification for staff performing resident transportation.
A resident with severe cognitive impairment and no prior history of wandering exited the facility unsupervised after a non-English-speaking lawn service worker held the front door open, unable to interpret posted warnings. The resident was found in the parking lot by a visitor after being outside for several minutes, highlighting a lapse in supervision and environmental safety protocols.
A resident with moderate cognitive impairment and a history of bipolar disorder received a new physician order for an auto-adjusting CPAP machine, but the care plan was not updated to reflect the new settings or equipment. The care plan continued to reference outdated CPAP parameters, and the IDT did not review or revise the plan to address the resident's updated respiratory therapy needs.
A resident with moderate cognitive impairment did not receive a physician-ordered C-Pap machine for several months due to the facility's failure to promptly transcribe and act on the order. The order was known to facility leadership but was not authorized or provided until a significant delay had occurred.
Two residents in an LTC facility were subjected to abuse by CNAs. One resident experienced physical abuse from a CNA who struck her during care, while another resident was verbally abused by a different CNA who made belittling and inappropriate remarks. Both residents had cognitive impairments, and the incidents were reported by a roommate and confirmed through facility investigations.
A resident with Alzheimer's and muscle weakness was left unable to eat during a meal due to unopened drink and out-of-reach utensils, contrary to her ADL care plan. The LPN and DON confirmed the oversight, acknowledging the necessity of staff assistance for meal setup.
A resident with moderate cognitive impairment was left unable to feed herself during a meal due to unopened drink and out-of-reach utensils. The facility's policy on meal assistance was not followed, as confirmed by the DON and Administrator.
Two residents were served meals that did not match the posted menu or facility recipes, leading to dissatisfaction. A club sandwich was listed, but residents received sandwiches lacking expected ingredients. The facility's policy required adherence to the menu, but dietary staff were unsure of the correct ingredients.
A resident with schizophrenia and vascular dementia was discharged from an LTC facility without a proper discharge notice. The notice lacked essential details such as the discharge plan, reason, and location, and was received late by the resident's representative. The resident was transferred to a hospital's behavioral health unit due to inappropriate behavior before the 30-day notice period ended. Staff interviews revealed a lack of experience in preparing discharge letters.
A resident experienced knee pain and a subsequent femoral fracture after a transfer incident involving a dead lift battery, leading to a manual transfer by CNAs. Despite the resident's complaints and a sitter's report, the LPN did not notify the physician or resident representative, violating facility policy. The resident had a history of hemiplegia and was cognitively intact.
A resident with a history of osteoporosis and hemiplegia experienced a failure in pain management when staff did not follow the care plan during a transfer, resulting in a fracture. The care plan required documentation and administration of pain medication, which was not done. The DON and Administrator confirmed the lapse in following the care plan.
A resident with a history of osteoporosis and hemiplegia suffered a right femur fracture during a transfer when the mechanical lift's battery failed. Despite the facility's no-lift policy, two CNAs manually transferred the resident, leading to the injury. The incident was not reported or investigated immediately, contrary to facility policy.
A resident with a history of osteoporosis and hemiplegia experienced pain after a manual transfer due to a dead lift battery. Despite complaints of pain, the LPN did not administer pain medication, violating the facility's pain management policy. The resident, cognitively intact, received a routine pain patch the following day, but no immediate relief was provided.
The facility failed to maintain proper food storage and labeling practices in the kitchen, as observed during an inspection. Issues included unlabeled and exposed food items, overly ripe produce with biological growth, and improperly stored dry goods. The Dietary Manager acknowledged these deficiencies, attributing them to a lack of oversight by the weekend cook. The Administrator was informed and expected daily monitoring of food safety practices.
A resident with moderately impaired cognition was placed in a wheelchair harness vest without a proper assessment or evaluation, contrary to facility policy. The vest was introduced by a family member and used without completing the necessary restraint decision form. The DON acknowledged the oversight, and the PT confirmed the lack of recent evaluation for the resident's posture.
A facility failed to properly store respiratory equipment for a resident, as required by their policy. Observations revealed that oxygen tubing was undated and not stored in a plastic bag when not in use. Interviews with LPNs and the DON confirmed the policy requirements, but staff admitted to not having seen the necessary storage bags. The resident had a diagnosis of Metabolic Encephalopathy and required oxygen for shortness of breath.
The facility failed to maintain an effective QAPI committee, resulting in a re-cited deficiency related to restraint management. A resident was not assessed for a least restrictive restraint, and the facility did not obtain a physician order for the use of a restraint for one of the residents reviewed.
A resident with quadriplegia was left unfed during a meal when a CNA was interrupted by an LPN to attend a meeting. The resident, who was dependent on staff for eating, expressed feeling disrespected and hungry as her food became cold. The CNA confirmed the incident, and the DON acknowledged the nurse's actions were inappropriate.
A resident with cognitive impairment accessed an unlocked medication cart and consumed Lactulose liquid due to the facility's failure to implement a care plan. The resident, known for rummaging and drinking inappropriate substances, was not adequately supervised, and the care plan interventions were not followed. The incident highlighted the need for staff to adhere to care plans to prevent such occurrences.
A resident with cognitive impairments accessed an unlocked medication cart and ingested Lactulose, highlighting a failure in maintaining a safe environment. The resident, known for rummaging behaviors, was able to open the cart due to an LPN's oversight. This incident was classified as Immediate Jeopardy and Substandard Quality of Care.
A facility failed to notify a resident's representative about changes in the resident's condition, specifically scratches on the chest, despite a policy requiring such communication. The resident, with severe cognitive impairment and multiple health conditions, had scratches noted during a body audit by the DON, who forgot to inform the representative. The oversight was discovered when the representative visited and filed a grievance.
The facility did not report an allegation of non-consensual sexual contact between residents to the State Agency within the required timeframe. An LPN observed inappropriate touching by a resident with dementia on two occasions and documented the incidents, but the RN Supervisor was not informed of the physical contact. The Social Service Director later reported the incidents to the Interdisciplinary Team, but the DON did not report them to the State Agency. The resident involved had a history of schizophrenia and moderate cognitive impairment.
A resident with wandering behaviors ingested a cleaning solution from an unsecured housekeeping cart. The facility's policy required hazardous chemicals to be locked when not in use, but this was not followed. The resident, with a history of dementia and behavioral disturbances, accessed the cart and consumed the solution, leading to immediate medical intervention.
The facility failed to manage and treat pain complaints for two residents when there was no licensed nurse available on their unit for approximately six hours and 45 minutes. One resident reported severe pain and did not receive her medication until later that night, while another resident with surgical-related pain was also left untreated. Staff interviews revealed a break in communication and staffing issues, leading to the deficiency.
Failure to Prevent, Report, and Investigate Verbal Abuse of a Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s right to be free from abuse and to protect residents from verbal and mental abuse after an allegation was reported. The facility’s own Abuse Policy defined verbal abuse as the use of disparaging and derogatory language and mental abuse as including humiliation, harassment, and threats of punishment or deprivation, and stated that residents were not to be subjected to abuse by anyone, including staff. Despite this, on the evening of 2/10/26, a resident was subjected to disparaging, demeaning, and derogatory language and deliberate actions intended to intimidate the resident by two CNAs during the provision of care. The resident repeatedly requested assistance and complained of pain, but was mocked, scorned, criticized, and insulted by the CNAs, and her complaints of discomfort, pain, and rough treatment were dismissed. The resident involved had been admitted with diagnoses including encounter for other orthopedic aftercare, fracture of the right femur, and dementia, and had a BIMS score of 11 indicating moderate cognitive impairment. The resident required a wheelchair for mobility, partial/moderate assistance for dressing and bed mobility, and one-person assistance for stand-pivot transfers with weight bearing as tolerated and caution due to right hip surgery. The resident’s care plan directed staff to provide assistance as needed for ADLs and transfers, and to anticipate and meet needs based on physical or non-verbal indicators of discomfort or distress. On the evening of 2/10/26, CNA #1 was assigned to the resident’s room and, along with CNA #2, provided care during which the abusive interaction occurred. Two other CNAs were present for part of the interaction, heard CNA #1 telling the resident to get up and that she was not handicapped, saw the resident attempt unsuccessfully to stand, and then left the room without reporting what they had heard. On 2/14/26 at approximately 8:40 AM, the resident’s representative reported an allegation of verbal abuse, supported by an audio recording, to the RN Supervisor. RN #1 and RN #2 listened to the recording with the resident and representative and described it as demeaning, degrading, cruel, and shocking, with the resident heard crying, screaming, complaining of pain and rough treatment, and begging the CNAs to stop while the CNAs mocked and laughed at her. RN #2 notified the DON at approximately 8:50 AM, and the DON notified the Administrator at approximately 9:01 AM. However, no interviews were conducted on 2/14/26, and the DON and Administrator did not come to the facility that day. The facility did not report the allegation to the State Agency within the required two-hour timeframe and did not begin a formal investigation until 2/15/26. During the investigation, the Lead CNA Supervisor and DON listened to the recording, recognized the voices of the resident and the two CNAs, and confirmed that the language and tone used were abusive, derogatory, demeaning, and malicious. CNA #2 later confirmed being present in the room throughout the incident and acknowledged being "guilty by association" for not reporting the abuse. The facility’s failure to immediately report, protect, and investigate after the allegation was made led to a finding of Immediate Jeopardy and Substandard Quality of Care under F600. The State Agency determined that Immediate Jeopardy began on 2/14/26 when the facility failed to protect residents from abuse, failed to report the alleged abuse timely, failed to promptly investigate the allegations, and administration failed to implement and enforce the facility’s abuse policies. The facility’s failure to report, protect, and investigate abuse placed all residents at risk in a situation likely to cause serious injury, serious harm, serious impairment, or death. The abusive conduct toward the resident, combined with the delayed response and lack of immediate protective measures after the allegation was reported, constituted the core deficiency identified by surveyors.
Removal Plan
- Resident #1 was moved from Unit A to Unit B at the request of the family after discussion with Registered Nurse #1.
- The Director of Nursing interviewed Resident #1 regarding the allegations of alleged abuse, and she denied any such happenings.
- The Director of Nursing assessed the resident for any physical or emotional effects.
- Psychosocial support was initiated and conducted for 72 hours by the Social Services Director.
- Resident #1 was referred to the Psychiatric Nurse Practitioner for evaluation.
- The Director of Nursing, Staff Development, and Lead CNA provided education with all staff regarding the Facility Abuse Policy and Procedures.
- A Corporate Nurse conducted an in-service with the Director of Nursing and Facility Administrator regarding abuse allegations, investigations, and proper reporting timeliness.
- CNA #1 was contacted multiple times to be terminated but did not return phone calls.
- CNA #2 was terminated upon review of the recording due to her voice being recognized using aggressive language.
- All staff will be educated on Abuse Policy and Procedure as well as the timeline for reporting and investigation of allegations of abuse by the Director of Nursing, Staff Development Nurse, Lead CNA, and RN Supervisor.
- No staff will be allowed to work until in-serviced.
- An AD HOC Quality Assurance meeting was held to review the plan for removal of the Immediate Jeopardy tag.
- The policy was reviewed with no changes.
Failure to Timely Report Verbal Abuse Allegation to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of verbal abuse to the State Agency (SA) within the required two-hour timeframe, as required by federal regulation and the facility’s own Abuse Policy and Procedure. The policy dated 1/24/22 states that any alleged incident reported must be investigated and reported to the state within two hours of knowledge of the alleged incident. On 2/14/26 at approximately 8:40 AM, the resident representative (RR) for Resident #1 reported an allegation of verbal abuse, supported by an audio recording, to facility nursing staff. The RR requested to speak with administration and provided access to the recording to two RNs. Record review and interviews show that the allegation was promptly communicated internally but not reported externally within the required timeframe. RN #2, the RN Supervisor on Unit A, notified the DON by telephone at approximately 8:50 AM on 2/14/26. The DON then notified the Administrator at approximately 9:01 AM the same morning. Despite this, the allegation of abuse was not initially reported to the SA until 2/16/26 at 11:30 AM, well beyond the two-hour reporting requirement. The facility’s own investigation documentation dated 2/19/26 confirms these times and the delay in reporting. Interviews with the DON, Administrator, RR, and RN #2 corroborate the sequence of events and the delay. The DON acknowledged being notified of the allegation on 2/14/26 at approximately 8:50 AM and stated she reported the allegation to the SA on 2/16/26 at 11:30 AM. The Administrator confirmed he was notified by the DON on 2/14/26 at about 9:00 AM and that the allegation was not reported to the SA until 2/16/26. The RR confirmed she reported the verbal abuse allegation and shared the recording with nursing staff on the morning of 2/14/26. The Administrator confirmed that the facility failed to report the allegation of abuse within the required timeframe according to state and federal requirements, resulting in a deficiency at 42 CFR 483.12(c)(1)(4) for failure to timely report alleged violations.
Removal Plan
- Move Resident #1 from Unit A to Unit B at the request of the family after discussion with the Registered Nurse.
- Interview Resident #1 regarding the allegations of abuse.
- Assess Resident #1 for any physical or emotional effects related to the allegations.
- Provide psychosocial support for 72 hours by the Social Services Director.
- Refer Resident #1 to the Psychiatric Nurse Practitioner for evaluation.
- Provide education to all staff regarding the Facility Abuse Policy and Procedures.
- Conduct an in-service with the Director of Nursing and Facility Administrator regarding abuse allegations, investigations, and proper reporting timeliness.
- Contact CNA #1 to proceed with termination.
- Terminate CNA #2 upon review of the recording due to use of aggressive language.
- Educate all staff on the Abuse Policy and Procedure and the timeline for reporting and investigation of allegations of abuse.
- Do not allow staff to work until they have been in-serviced.
- Hold an AD HOC Quality Assurance meeting to review the plan for removal of the Immediate Jeopardy tag.
- Review the policy.
Failure to Timely Investigate Verbal Abuse Allegation and Implement Protective Measures
Penalty
Summary
The deficiency involves the facility’s failure to promptly and thoroughly investigate an allegation of verbal abuse and to implement immediate protective measures after the allegation was reported. On 2/14/26 at approximately 8:40 AM, the resident representative (RR) for Resident #1 reported an allegation of verbal abuse to the RN Supervisor (RN #2), including an audio recording made on the resident’s cell phone that captured staff cursing at the resident while the resident was heard screaming. RN #2 notified the DON by telephone at approximately 8:50 AM, and the DON notified the Administrator at approximately 9:01 AM. Staff who heard the recording, including RN #1 and RN #2, considered the interaction abusive and were able to identify the voice of Resident #1, though they did not initially recognize the staff voices. Despite this, the Administrator and DON did not come to the facility on 2/14/26, and no formal investigation was initiated that day. The facility’s own Abuse Policy and Procedure, dated 1/24/22, required that all alleged violations be thoroughly investigated under the direct supervision of the Administrator, that all necessary steps be taken to prevent further potential abuse while the investigation was in progress, and that any employee suspected of abuse be suspended pending investigation. The policy also required that residents be protected from harm through frequent supervision and reassurance during and after the investigation. Contrary to this policy, on 2/14/26 there were no interviews of staff or other residents, no documented resident assessments for signs or symptoms of abuse, and no protective interventions implemented beyond moving Resident #1 to another unit. The DON stated she had instructed RN #1 to follow up on 2/14/26 at approximately 10:00 AM but was not aware of any interviews or other investigative steps taken that day. RN #1 confirmed that she did not conduct any interviews, did not assess any residents, and did not place any interventions in place to protect residents on 2/14/26. The investigation did not substantively begin until 2/15/26 and 2/16/26. The DON reported to the facility on 2/15/26 at approximately 10:00 AM and conducted a single interview with Resident #1 and attempted, unsuccessfully, to locate the recording on the resident’s cell phone; she did not contact the RR or conduct any other interviews that day. On 2/16/26, the DON contacted the RR for the first time since the initial notification, obtained the audio recording at approximately 11:16 AM, and, together with the Lead CNA Supervisor, listened to it and identified the voices of Resident #1, CNA #1, and CNA #2. The DON also determined that CNA #2 had been present during the incident and ascertained that the incident date was 2/10/26. Interviews of other residents were delegated to the Social Services Director, who reported interviewing four residents on one hall on 2/19/26. Throughout the period from 2/14/26 until 2/16/26, the facility did not immediately suspend all staff suspected of involvement, and staff alleged to be involved continued to provide resident care, despite the existence of an audio recording that facility staff and administration validated as capturing abusive language toward Resident #1. The Administrator confirmed that he had delegated responsibility for investigating the allegation to the DON and was unaware of any staff interviews conducted prior to 2/16/26. Multiple staff, including the DON, RN #1, RN #2, and the Social Services Director, acknowledged that failure to thoroughly investigate an allegation of abuse could result in continued abuse of residents. The State Agency determined that the facility’s failure to initiate a timely investigation and implement protective measures after the allegation was reported on 2/14/26 created the likelihood of continued abuse of Resident #1 and other residents and placed them in a situation likely to cause serious harm, serious injury, serious impairment, or death. This failure resulted in Immediate Jeopardy and Substandard Quality of Care at 42 CFR 483.12(c)(2), Investigation of Alleged Violations, with an initial scope and severity level of J.
Removal Plan
- Moved Resident #1 from Unit A to Unit B at the request of the family after discussion with RN #1.
- DON interviewed Resident #1 regarding the allegations; Resident #1 denied the allegations.
- DON assessed Resident #1 for any physical or emotional effects.
- Psychosocial support was initiated and provided for 72 hours by the SSD.
- Referred Resident #1 to the Psychiatric Nurse Practitioner for evaluation.
- DON, Staff Development, and Lead CNA provided education to all staff regarding the Facility Abuse Policy and Procedures.
- Corporate Nurse conducted an in-service with the DON and Facility Administrator regarding abuse allegations, investigations, and proper reporting timeliness.
- CNA #1 was contacted multiple times to be terminated due to being a no show and not having worked; CNA #1 did not return phone calls.
- CNA #2 was terminated upon review of the recording due to her voice being recognized using aggressive language.
- Educated all staff on the Abuse Policy and Procedure and the timeline for reporting and investigation of allegations of abuse; no staff were allowed to work until in-serviced.
- Held an AD HOC QA meeting to review the plan for removal of the IJ tag.
- Reviewed the policy with no changes.
Failure to Timely Report and Investigate Verbal Abuse Allegation and Remove Alleged Perpetrator
Penalty
Summary
The deficiency involves the facility’s failure to administer operations in a way that ensured timely and effective response to an allegation of verbal abuse. A resident representative reported an allegation of verbal abuse involving Resident #1 on 2/14/26 at approximately 8:40 AM to an RN supervisor, providing an audio recording in which staff were heard cursing at the resident while the resident was heard screaming. The RN supervisor notified the DON at approximately 8:50 AM, and the DON notified the Administrator at approximately 9:01 AM. Despite this, the Administrator, who acknowledged awareness of state and federal reporting timeframes and whose job description includes ensuring reportable events are reported within regulatory requirements, did not ensure the allegation was reported to the State Agency within the required timeframes. The facility also failed to implement immediate protective measures and to promptly initiate an investigation after the allegation was reported. Staff schedules and interviews showed that the alleged perpetrator, CNA #2, continued to work in the facility after the allegation was reported on 2/14/26 and remained on duty until 2/16/26 at approximately 11:16 AM, when employment was terminated. Staff confirmed that neither the Administrator nor the DON came to the facility on 2/14/26 and that no staff interviews were conducted that day. The only intervention implemented on 2/14/26 was relocating Resident #1 to another unit at the request of the resident representative. Record review indicated that the facility had an Abuse Policy and Procedure requiring residents to be free from verbal, physical, mental, and sexual abuse and requiring that allegations of abuse be reported and investigated in accordance with regulatory requirements. The facility’s own investigation documented that the allegation was not reported to the State Agency until 2/16/26 and that staff interviews did not begin until 2/16/26. The Administrator confirmed being notified of the allegation on 2/14/26 at approximately 9:00 AM and confirmed awareness of the regulatory timeframes for reporting allegations of abuse. The facility did not have a separate Administration Policy, but the Administrator’s job description required leading operations in accordance with regulations and ensuring reportable events such as alleged abuse are reported to the correct entity within required timeframes.
Removal Plan
- Moved Resident #1 from Unit A to Unit B at the request of the family after discussion with Registered Nurse #1.
- Director of Nursing interviewed Resident #1 regarding the allegations of abuse, and she denied any such happenings.
- Director of Nursing assessed Resident #1 for any physical or emotional effects.
- Provided psychosocial support for 72 hours by the Social Services Director.
- Referred Resident #1 to the Psychiatric Nurse Practitioner for evaluation.
- Director of Nursing, Staff Development, and Lead CNA provided education to all staff regarding the Facility Abuse Policy and Procedures.
- Corporate Nurse conducted an in-service with the Director of Nursing and Facility Administrator regarding abuse allegations, investigations, and proper reporting timeliness.
- Contacted CNA #1 multiple times to proceed with termination.
- Terminated CNA #2 upon review of the recording due to use of aggressive language.
- Educated all staff on the Abuse Policy and Procedure and the timeline for reporting and investigation of allegations of abuse.
- Prohibited staff from working until in-serviced.
- Held an ad hoc Quality Assurance meeting to review the plan for removal of the Immediate Jeopardy tag.
- Reviewed the policy with no changes.
Failure to Reposition Dependent Residents per Two-Hour Standard of Care
Penalty
Summary
The deficiency involves the facility’s failure to provide turning and repositioning assistance according to standards of care and facility policy for two dependent residents who required ADL support. The facility’s ADL CARE POLICY dated August 2023 states that residents are to receive appropriate treatment and services to ensure all ADL needs are met daily. For Resident #1, observations on 1/12/26 at 9:30 AM showed the resident resting in bed on her back with the head of the bed elevated, with a family member present. At 2:00 PM, the family member reported she had been in the room continuously since before 9:30 AM and that the resident had not been turned or repositioned during that time. CNA #2, assigned to Resident #1 on the 7:00 AM–3:00 PM shift, confirmed at 2:56 PM that she had turned/repositioned the resident only once prior to 9:30 AM and acknowledged that the resident was supposed to be turned every two hours while in bed. Record review showed Resident #1 had diagnoses including cerebral infarction and dysphagia, severely impaired cognitive skills, and was assessed as dependent for bed mobility. For Resident #2, on 1/12/26 at 11:15 AM, observation and interview revealed the resident was lying on his back in bed, alert and oriented, reporting bilateral leg discomfort and stating he had not been repositioned since approximately 5:00 AM when a male CNA turned him onto his back. At 11:22 AM, CNA #1 entered and repositioned him onto his left side with a foam wedge, stating this was the first time she had turned him that day. In a 3:22 PM interview, CNA #1 stated the resident required repositioning every two hours and that she did not know when he had last been turned before 11:22 AM. The RN Supervisor, interviewed at 3:30 PM, stated he had been responsible for the care of both residents until approximately noon, had arrived at about 6:43 AM, and was not aware that Resident #2 had not been turned during the 7:00 AM–3:00 PM shift until 11:22 AM, nor that Resident #1 had not been turned for approximately five hours. He attributed the postponement of care to lack of communication and acknowledged he had not checked on Resident #2. The Administrator and DON both stated their expectations that nurses and RN Supervisors supervise care and that residents be turned/repositioned every two hours and as needed to avoid discomfort and damage to skin integrity. Record review for Resident #2 showed admission with diagnoses including congestive heart failure and cervical region spondylosis with myelopathy.
Improper Medication Storage and Labeling on Medication Cart
Penalty
Summary
Surveyors identified a deficiency in the facility’s medication storage and labeling practices involving one of three medication carts, specifically the 400 Hall medication cart. The facility’s written policy on medical supply storage, dated March 2011, did not address the practice of storing one medication inside the packaging of another medication. A Medication Error Report dated 12/29/25 documented that individual Restasis vials were found inside a nebulizer medication box, and a family member reported that the wrong vial had been brought into a resident’s room. The Administrator stated he expected nurses to maintain accurate storage of medications to ensure safe administration and acknowledged that storing one medication in the box of a different medication could lead to administration of the wrong medication. The DON confirmed that on 12/29/25 she was notified by the family of a resident that a nurse had entered the resident’s room with an incorrect vial for a nebulizer treatment. During her investigation, she found multiple vials of Restasis eye drops stored inside an Albuterol Sulfate Inhalation Solution package labeled with the resident’s name. The resident involved had been admitted with diagnoses including cerebral infarction (stroke) and dysphagia, and an MDS assessment dated 11/12/25 documented that the resident was rarely or never understood and had severely impaired cognitive skills for daily decision making. The resident’s representative reported that when the nurse entered the room and announced she was going to administer a nebulizer treatment for congestion, the representative observed that the vial was obviously not the correct medication and pointed this out, after which the nurse left the room without placing the medication into the nebulizer unit.
Failure to Follow Care Plan for Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when the facility failed to implement a comprehensive, person-centered care plan for a resident who required assistance with activities of daily living due to quadriplegia and muscle weakness. The resident's care plan specified that all surface-to-surface transfers must be performed using a total mechanical lift with the assistance of two nursing staff members. Despite this, during a bed-to-Geri-recliner transfer, one CNA attempted to transfer the resident alone, without waiting for the second CNA to assist, and did not lock the Geri-recliner or open the base of the lift as required by policy. As a result of these actions, the resident, who was dependent for mobility and transfers and had additional conditions such as colostomy, contractures, paralysis, and pressure ulcers, was observed on the floor with the transfer sling beneath him and the mechanical lift and Geri-recliner overturned. The incident led to the resident sustaining an acute displaced fracture of the left anterolateral rib, as confirmed by hospital imaging. The resident reported pain immediately following the incident and required pain management upon return to the facility. Interviews with facility staff and review of records confirmed that all CNAs had access to care instructions via facility software and had received training on the requirement for two staff members during mechanical lift transfers. Both CNAs involved in the incident acknowledged the policy and their failure to follow it, which directly resulted in the resident's fall and injury. The facility's investigation corroborated that the transfer was performed in violation of established protocols.
Failure to Prevent Accidents Due to Inadequate Supervision and Staff Training
Penalty
Summary
The facility failed to ensure adequate supervision and implementation of safety interventions to prevent accidents for two residents. In the first incident, a resident who was dependent for transfers and required the use of a mechanical lift with two staff members was transferred by a single CNA without assistance. The CNA did not lock the Geri-recliner or open the base of the lift, resulting in the resident falling to the floor and sustaining a rib fracture. Both CNAs involved had received training indicating that two staff were required for mechanical lift transfers, but the procedure was not followed, and the incident was confirmed by interviews and documentation. In the second incident, another resident was being transported back to the facility from a hospital in a wheelchair via the facility van. During transport, the wheelchair moved and tilted backward, causing the resident, still in the wheelchair, to fall onto the floor of the van. The CNAs responsible for the transport had not received formal training or competency checks for the use of the van's securement system. The DON provided only a verbal explanation of the securement process without demonstration or requiring return demonstration. The resident did not sustain injury, but the event was reported and confirmed by the resident, staff, and documentation. Both incidents involved residents with significant medical histories and physical impairments. The first resident had acute respiratory failure, lack of coordination, osteoporosis, and was dependent for transfers. The second resident had acute kidney failure, cognitive communication deficit, vascular dementia, and muscle weakness, and required a wheelchair for mobility. The deficiencies were directly related to staff not following established policies and lack of adequate training or supervision during critical procedures, resulting in preventable accidents.
Failure to Ensure Staff Competency in Resident Transportation
Penalty
Summary
The facility failed to ensure that staff responsible for transporting residents possessed and demonstrated the necessary competencies to safely carry out their duties. Specifically, the facility's policy on transportation did not address requirements or training qualifications for staff performing resident transportation. Record review and staff interviews revealed that two CNAs who transported a resident from a hospital back to the facility had not received formal training, demonstration, or competency checkoff for the operation of the facility van, its lift, or the resident securement system. Both CNAs confirmed they had not been trained in the safe use of the securement system prior to the incident. During the transport, the resident, who had severe cognitive impairment and required assistance for transfers and mobility, experienced an incident where his wheelchair turned over backwards and landed on the floor of the van. The CNAs assisted the resident, who remained in the wheelchair, back to an upright position and completed the transport. The LPN evaluated the resident upon return and found no injury or complaints of pain. The incident was reported to the resident's representative, primary healthcare provider, and the Director of Nursing, and an incident report was completed. Further interviews revealed that the Maintenance Supervisor, responsible for training staff on the van and securement system, had just started in the position and had not yet provided any training. The DON stated she had only verbally explained the securement system to the CNAs without demonstration or requiring return demonstration. Personnel files for the CNAs involved showed no documentation of training specific to the operation of the facility van or securement system. The lack of formal training and competency verification directly contributed to the unsafe transport of the resident.
Failure to Prevent Unsupervised Exit of Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment exited the facility unsupervised through the front door, which was held open by a lawn service worker. The resident, who had a BIMS score of 7 indicating severe cognitive impairment and diagnoses including heart failure and vascular dementia, was not identified as an elopement risk and had no prior history of wandering behaviors. Despite this, the resident was able to leave the building in her wheelchair without staff noticing. The incident took place when a lawn care worker, who did not speak or read English, opened and held the facility's front door while waiting to exit after completing work in the inner courtyard. The worker was unable to interpret the posted signage instructing individuals not to allow residents to exit. As a result, the resident followed the worker outside and was left unsupervised in the facility's parking lot for approximately three minutes before being found by a visitor. Staff interviews and record reviews confirmed that the resident was last seen inside the facility at 11:05 AM and was found at 11:08 AM, approximately 145 feet from the front door. The resident was assessed and found to be in no distress, and all other residents were accounted for following the incident. The facility's policy required the environment to be as free from accident hazards as possible and for residents to receive adequate supervision to prevent accidents, but these measures were not effectively implemented in this case.
Failure to Update Care Plan for New CPAP Order
Penalty
Summary
The facility failed to develop and revise a comprehensive care plan in accordance with physician orders and professional standards for one resident who required respiratory equipment. Specifically, after a new physician order was issued for an auto-adjusting CPAP machine with a pressure range of 8-18 cm H2O and modem setup, the facility did not update the resident's care plan to reflect this change. The care plan continued to reference an outdated CPAP setting of 4 cm H2O, and there was no documentation that the interdisciplinary team reviewed or implemented updated interventions related to the new therapy. Record reviews confirmed that the resident, who had a history of bipolar disorder and moderate cognitive impairment, received the new CPAP machine but the care plan was not updated accordingly. Interviews with the LPN/MDS Coordinator, DON, and Administrator all confirmed that the new physician order was not incorporated into the care plan and that the interdisciplinary team did not review or revise the plan to address the resident's updated respiratory needs.
Failure to Timely Transcribe and Provide Ordered C-Pap Equipment
Penalty
Summary
The facility failed to ensure that services were provided and documented according to professional standards for one resident who required a new Continuous Positive Airway Pressure (C-Pap) machine. A physician's order for a new C-Pap machine was issued on 1/31/25 following a sleep study, but the order was not transcribed or acted upon until nearly four months later. The facility's policy requires that physician orders be transcribed and followed as written, with clarification obtained when needed. However, the order for the new C-Pap machine was not entered, and the resident did not receive the prescribed equipment until 5/28/25. The resident involved had a history of bipolar disorder and was assessed as moderately cognitively impaired. Documentation showed that the resident was only fitted for and received the C-Pap machine after a significant delay. Interviews with the DON and Administrator confirmed that the order was known to facility leadership shortly after it was written, but authorization to obtain the equipment was not given until months later. The nurse practitioner also confirmed the importance of timely provision of the C-Pap machine as ordered by the pulmonologist.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect two residents from abuse, violating their right to be free from all forms of abuse. Resident #1 was involved in two separate incidents. In the first incident, Resident #1's roommate reported hearing Resident #1 say, 'Stop hitting me,' followed by a popping sound and a scream during care provided by CNA #1. In the second incident, Resident #1 was subjected to verbal abuse by CNA #2, who made belittling and inappropriate remarks about the resident's appearance and past experiences. These incidents were reported by Resident #1's roommate, who also provided an audio recording of the verbal abuse. Resident #2 reported being physically abused by CNA #1, who struck her on the knuckles during care when she did not release her grip on a positioner. Resident #2 recalled the incident clearly, stating that she was told to let go and was struck when she did not comply immediately. Both residents involved had cognitive impairments, with Resident #1 having severe cognitive impairment and Resident #2 having moderate cognitive impairment, as indicated by their BIMS scores. The facility's policy on preventing resident abuse was not adhered to, as evidenced by the incidents involving CNAs #1 and #2. The facility's investigations confirmed the allegations, and both CNAs were suspended and subsequently terminated. The incidents were reported to the State Agency certification division, but the report does not mention any immediate jeopardy or removal plan being submitted by the facility.
Failure to Implement ADL Care Plan for Resident
Penalty
Summary
The facility failed to implement care plan interventions for a resident requiring assistance with Activities of Daily Living (ADL) due to muscle weakness and Alzheimer's Disease. During an evening meal observation, the resident was found alone in her room with her supper tray on the over-the-bed table. The resident's soda can was unopened, and her utensils were placed out of reach, preventing her from eating and drinking independently. The resident confirmed her inability to open the can and locate her utensils, which were essential for her to feed herself. The Licensed Practical Nurse (LPN) and the Director of Nursing (DON) confirmed that the resident's care plan required staff to assist with meal setup, including opening containers and ensuring utensils were within reach. The facility's failure to adhere to the care plan interventions was acknowledged by the DON and Administrator, who confirmed that such assistance was expected as part of the resident's ADL care plan. The resident's medical history included Alzheimer's Disease, Glaucoma, Muscle Weakness, and Diabetes, which necessitated the need for assistance with ADLs.
Failure to Assist Resident with Dining Needs
Penalty
Summary
The facility failed to provide appropriate services to maintain a resident's ability to perform activities of daily living, specifically dining and eating. During an observation, it was noted that a resident was left alone in her room with her supper tray placed on an over-the-bed table. The resident's soda can was unopened, and her utensils were out of reach, preventing her from feeding herself. The resident confirmed her inability to open the soda can and locate her utensils, which hindered her ability to eat independently. This incident was observed by a Licensed Practical Nurse and the Director of Nursing, who acknowledged that the drink should have been opened and the utensils placed within reach as part of the meal set-up assistance. The resident involved in this deficiency was admitted to the facility with diagnoses including Alzheimer's Disease, Glaucoma, Muscle Weakness, and Diabetes. A review of her Quarterly Minimum Data Set indicated a Brief Interview for Mental Status score of 9, suggesting moderate cognitive impairment. The facility's policy on meal assistance clearly outlines the need to ensure that residents can reach their utensils and have their food and drink prepared for consumption, which was not adhered to in this case. The Director of Nursing and the Administrator confirmed that the assistance for eating should include opening containers and ensuring utensils are accessible during tray set-up.
Failure to Serve Palatable Meals as Per Menu
Penalty
Summary
The facility failed to provide a meal that was palatable in appearance and consistent with the posted menu for two residents. On the evening of 3/19/25, the menu listed a club sandwich, but the sandwiches served did not match the facility's recipe or the residents' expectations. Resident #4 received a slice of ham on an intact hoagie bun without vegetables, chips, or French fries, which she found difficult to eat. Similarly, Resident #3 was served a sandwich with small ham squares and mayonnaise on a hoagie bun, lacking the expected ingredients of a club sandwich. Both residents expressed dissatisfaction with the meal's appearance and composition. The facility's policy required that foods be served as planned on the menu unless there was a legitimate reason for deviation. Interviews with the Administrator and dietary staff confirmed that the posted menus should be followed and that recipes were available online. The Dietary Manager in Training was unsure of the correct ingredients for a club sandwich, indicating a lack of adherence to the facility's menu and recipe guidelines. Resident #4, with no cognitive impairment, and Resident #3, with severe cognitive impairment, both experienced meals that did not meet the facility's standards or their expectations.
Deficient Discharge Notice for Resident
Penalty
Summary
The facility failed to ensure that the written notice of discharge for a resident included all required elements for a facility-initiated discharge. The discharge letter, dated and sent by certified mail, was received by the resident's representative 12 days after it was dated. The letter did not include a discharge plan, an actual discharge date, the reason for discharge, the location to which the resident was being discharged, or the contact information for the agency responsible for protection and advocacy of individuals with a mental disorder. The resident's brother expressed concerns about the lack of communication and the insufficient notice period before the discharge. The resident, who had been diagnosed with schizophrenia and vascular dementia with behavioral disturbance, was transferred to a hospital's behavioral health unit due to inappropriate sexual behavior towards staff and residents. The transfer occurred before the 30-day notice period had elapsed, as the resident was moved to the hospital three days before the discharge date mentioned in the notice. Interviews with facility staff revealed a lack of understanding and experience in preparing discharge letters, contributing to the deficiency in the discharge process.
Failure to Notify Physician and Resident Representative After Transfer Incident
Penalty
Summary
The facility failed to notify the physician or the resident representative when a resident experienced pain in her right knee after a transfer incident, which resulted in a femoral fracture diagnosed the following day. The incident involved a resident who required a mechanical lift for transfers. During the transfer, the lift battery was dead, and while the nurse was fetching a replacement, the resident began sliding out of the chair. To prevent a fall, two CNAs manually transferred the resident, during which she yelled out in pain. Despite the resident's complaints of pain and the sitter's report, the LPN did not notify the necessary parties as per the facility's policy. The resident, admitted in 2018, had a history of hemiplegia and hemiparesis following a cerebral infarction and was cognitively intact with a BIMS score of 14. Interviews with the CNAs and the LPN revealed that the CNAs did not inform the LPN about the resident's scream during the transfer. The DON and the facility administrator confirmed that the facility's policy was not followed, as the physician, DON, and resident representative were not notified of the incident and the resident's pain complaints.
Failure to Implement Pain Management Care Plan
Penalty
Summary
The facility failed to implement care plan interventions related to pain management for a resident who yelled out in pain during a transfer. The care plan for the resident, who was at risk for pain, included documenting the type, location, and severity of pain and administering medications as ordered. However, on the day of the incident, the resident complained of right leg pain, and no pain medication was administered. The resident was later found to have a right distal femur fracture after being transferred to a hospital. Interviews with facility staff revealed that the Licensed Practical Nurse (LPN) on duty did not administer the prescribed pain medication or report the resident's pain to the oncoming nurse. The Director of Nursing (DON) and the Administrator confirmed that the care plan interventions were not followed, as the staff failed to administer pain medication and document the resident's pain. The resident had been admitted to the facility with diagnoses including age-related osteoporosis and hemiplegia following a cerebral infarction.
Failure to Ensure Safe Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to ensure a resident was free from accidents and hazards during a transfer process, which resulted in a right femur fracture for the resident. The incident involved a resident who was care planned for transfers via a mechanical lift. During the transfer, the battery of the mechanical lift was found to be dead, and while a nurse went to retrieve a new battery, the resident began sliding out of the wheelchair. In an attempt to prevent the resident from falling, two CNAs manually transferred the resident by lifting the lift pad, which was not in accordance with the facility's no-lift policy. The resident, who had a history of age-related osteoporosis and hemiplegia following a cerebral infarction, was cognitively intact at the time of the incident. The CNAs involved in the transfer did not report the resident's scream during the manual transfer, and the nurse did not investigate further or report the incident to the unit manager or DON. The facility's policy required incidents and accidents to be investigated immediately, but this was not adhered to in this case. Interviews with the staff and the resident's sitter revealed that the lift pad straps were detached from the mechanical lift, and the CNAs decided to manually transfer the resident despite the facility's no-lift policy. The DON and Administrator were not informed of the incident until after the resident was diagnosed with a femur fracture at the hospital. The facility's failure to follow proper procedures and ensure adequate supervision during the transfer process led to the resident's injury.
Failure in Pain Management for Resident Post-Transfer
Penalty
Summary
The facility failed to provide appropriate pain management for a resident who complained of pain following a manual transfer from her wheelchair to the bed. The incident occurred when the lift battery was dead, and the CNAs manually transferred the resident, resulting in her screaming out in pain. Despite the resident's complaint of pain, the LPN on duty did not administer any pain medication on the day of the incident, which was against the facility's pain management policy. The resident, who was cognitively intact with a BIMS score of 14, had a medical history including age-related osteoporosis and hemiplegia following a cerebral infarction. The following day, the resident received a routine Duragesic patch for pain, but no immediate pain relief was provided after the incident. The facility's investigation confirmed that the staff failed to follow the pain management policy, as acknowledged by both the DON and the Administrator.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a kitchen inspection. The inspection revealed multiple instances of improper food storage and labeling, including unlabeled food items, exposed food, and overly ripe produce with biological growth. Specifically, in Refrigerator #1, there were overly ripe green tomatoes, cucumbers, and bell peppers with bio-growth, and several food items such as sweet potatoes, tomato soup, scrambled eggs, gravy, and bacon were found without labels and improperly covered. Additionally, there were trays of juices and thickened beverages without labels, and opened cartons of thickened juices lacked proper labeling of open dates. Unlabeled condiment cups and a smoothie bottle were also found, with the Dietary Manager unable to identify the owner of the smoothie. Further inspection of the pantry revealed a scoop improperly stored inside a flour bin, open containers of garlic seasoning, and several opened containers of sauces that required refrigeration according to the manufacturer's label. The Dietary Manager confirmed the presence of overly ripe produce, exposed foods, and the failure to refrigerate perishable items, attributing the oversight to the weekend cook's failure to check for spoiled and expired foods. The Administrator was informed of these findings and stated an expectation for kitchen staff to monitor food storage and labeling daily to ensure food safety.
Failure to Assess and Evaluate Use of Physical Restraint
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints by not completing an assessment and evaluation for an upper body harness vest and not ensuring it was the least restrictive device. The facility's policy mandates that restraints should only be used for the safety and well-being of residents after other alternatives have been tried unsuccessfully and with informed consent. However, for the resident in question, the necessary assessment and evaluation were not conducted, and the restraint decision form was not completed prior to the application of the restraint. The resident, who was admitted with a diagnosis of metabolic encephalopathy and had a moderately impaired cognitive status, was observed using a wheelchair harness vest. The vest was brought in by a family member and used without a proper assessment. The Director of Nursing admitted that the assessment and evaluation were missed, and the staff had not received in-service training for the device. The Physical Therapist confirmed that the resident had not been recently evaluated for posture and would not recommend restraints without a thorough assessment.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to ensure proper storage of respiratory equipment for a resident, as evidenced by observations of undated and unbagged oxygen tubing. The facility's policy, dated April 2007, required that all respiratory tubing be replaced weekly, dated, and stored in a dated plastic bag when not in use to decrease the risk of exposure to infectious diseases and contaminants. However, during multiple observations, the oxygen tubing on the resident's wheelchair was found to be undated and not stored in a plastic bag, despite the resident using a bedside concentrator while in bed. Interviews with facility staff, including LPNs and the Director of Nursing, confirmed the policy requirements for changing and storing respiratory tubing. LPN #4 admitted to never having seen the required storage bags, and LPN #1 reiterated the policy's intent to reduce exposure risks. The Director of Nursing stated that it was the cart nurse's responsibility to manage the tubing, with changes typically occurring on the Sunday night to Monday morning shift. The resident involved had a diagnosis of Metabolic Encephalopathy and had an active order for oxygen use as needed for shortness of breath.
Deficiency in Restraint Management and QAPI Committee
Penalty
Summary
The facility failed to sustain an effective Quality Assurance and Performance Improvement (QAPI) committee, as evidenced by a re-cited deficiency originally identified in July 2023 during an annual recertification survey. The deficiency involved the facility's failure to ensure a resident was free from physical restraints. Specifically, the facility did not assess for a least restrictive restraint for one resident and failed to obtain a physician order for the use of a restraint for one of the three residents reviewed for restraints.
Resident Left Unfed Due to Staff Meeting Interruption
Penalty
Summary
The facility failed to accommodate the needs of a resident who was dependent on staff for eating, resulting in the resident being left unassisted and unfed during a meal. The incident involved a resident with quadriplegia and complete muscle weakness, who was cognitively intact. During a meal, a CNA was feeding the resident when an LPN interrupted and demanded the CNA attend a meeting, leaving the resident with a meal tray in front of her. The resident expressed feeling disrespected and hungry as she had to wait for the CNA to return, and her food had become cold. The CNA confirmed that she was feeding the resident when the LPN insisted she stop and attend a meeting. Despite initially continuing to feed the resident, the CNA eventually complied with the LPN's demand, leaving the resident unattended for about twenty to thirty minutes. Upon returning, the CNA found the resident's food cold and took steps to provide warm food, further delaying the meal. The Director of Nursing acknowledged that the resident should have been fed first and that the nurse's actions were inappropriate.
Failure to Implement Care Plan Leads to Resident Accessing Medication Cart
Penalty
Summary
The facility failed to implement a care plan to prevent a resident's access to a medication cart, resulting in a resident opening an unlocked medication cart and consuming Lactulose liquid. This incident involved a resident with moderate cognitive impairment and impaired communication ability, who was known to be at risk for self-harm by removing items from the medication cart and placing them in their mouth. The care plan for this resident included interventions such as keeping all medication carts locked and free of harmful items. On the day of the incident, a Licensed Practical Nurse (LPN) assigned to the resident's care observed the resident seated next to the medication cart with an open drawer and a bottle of Lactulose in hand. The LPN was not aware of the care plan interventions related to the resident's cognitive impairment and risk for self-harm. The Director of Nurses (DON) and the facility Administrator were aware of the resident's history of rummaging and drinking inappropriate substances, and the care plan addressed these risk factors. The incident report indicated that the resident consumed approximately 60 cc of Lactulose, and immediate actions were taken, including contacting Poison Control and a Nurse Practitioner. Interviews with facility staff revealed that the care plan was not followed, and the medication cart was left unlocked and unattended, allowing the resident to access the medication. The facility's policy required all employees to follow the written care plan to meet the residents' needs, which was not adhered to in this case.
Removal Plan
- The care plan is being followed for Resident #1.
- Resident #1 is having one on one supervision at all times.
- A nurse was assigned to the dementia unit each shift for increased supervision for cognitively impaired residents who reside there.
- Resident #1 has been assessed for injuries with no adverse effects noted.
- Resident Representative attempted to be notified by phone at time of incident with no success. Several phone attempts were followed up by facility with no success. Letter mailed to resident representative for notification of incident.
- The Director of Nursing (DON), Staff Development, Administrator and Registered Nurse (RN) Supervisors provided education to staff whom are directly involved in passing medication and responsible for medication carts.
- An emphasis was placed on ensuring all carts in the facility are always locked when not in attendance.
- In-service also including following the care plan for Resident #1.
- In-service is ongoing and continues until all nurses are educated prior to working their shift.
- There is a designated nurse assigned to the dementia unit each shift to increase supervision of cognitively impaired residents.
- The Director of Nursing (DON), Staff Development, Administrator and Registered Nurse (RN) Supervisors provided education on the one on one supervision on Resident #1.
- This in-service is ongoing and will continue until all nursing staff have been in-serviced prior to working their scheduled shift.
- The Minimum Data Set (MDS) nurse updated the care plan and Kardex to reflect the need for one on one supervision.
- Behavior monitoring has been ongoing with this resident but was updated to include the behavior of rummaging.
- The DON or Staff Development Nurse has assigned a staff member each shift to make rounds every 30 minutes to check that all carts in the facility are locked.
- The Director of Nursing, Staff Development Nurse or Registered Nurse Supervisor are assigned to audit the one on one supervision sheets on a daily basis for compliance with one on one supervision of Resident #1.
- AD HOC Quality Assurance (QA) meeting held to review plans for removal of Immediate Jeopardy (IJ) tag.
Resident Accesses Unlocked Medication Cart
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards, as evidenced by an incident involving a resident who accessed an unlocked and unattended medication cart. The resident, who had a history of rummaging and consuming inappropriate substances, managed to open the cart and ingest a bottle of Lactulose. This incident was classified as an Immediate Jeopardy and Substandard Quality of Care, indicating a serious breach in safety protocols that could lead to significant harm. The resident involved in the incident had been admitted to the facility with diagnoses including Dementia with Behavioral Disturbance, Impulse Disorder, and a history of Traumatic Brain Injury. The resident was known to have cognitive limitations, wandering behaviors, and a tendency to consume liquids not intended for ingestion. On the day of the incident, a Licensed Practical Nurse (LPN) inadvertently left the medication cart unlocked while stepping away, allowing the resident to access and drink from a bottle of Lactulose. Interviews with facility staff, including the LPN involved, the Director of Nurses (DON), and the Administrator, revealed awareness of the resident's behaviors and the necessity for secure storage of medications. Despite this knowledge, the failure to ensure the medication cart was locked resulted in the resident's access to the medication. The incident highlighted the need for strict adherence to safety protocols to prevent similar occurrences in the future.
Removal Plan
- The care plan is being followed for Resident #1.
- Resident #1 is having one on one supervision at all times.
- A nurse was assigned to the dementia unit each shift for increased supervision for cognitively impaired residents who reside there.
- Resident #1 has been assessed for injuries with no adverse effects noted.
- Resident Representative attempted to be notified by phone at time of incident with no success. Several phone attempts were followed up by facility with no success. Letter mailed to resident representative for notification of incident.
- The Director of Nursing (DON), Staff Development, Administrator and Registered Nurse (RN) Supervisors provided education to staff whom are directly involved in passing medication and responsible for medication carts.
- An emphasis was placed on ensuring all carts in the facility are always locked when not in attendance.
- In-service also including following the care plan for Resident #1.
- In-service is ongoing and continues until all nurses are educated prior to working their shift.
- There is a designated nurse assigned to the dementia unit each shift to increase supervision of cognitively impaired residents.
- The Director of Nursing (DON), Staff Development, Administrator and Registered Nurse (RN) Supervisors provided education on the one on one supervision on Resident #1.
- This in-service is ongoing and will continue until all nursing staff have been in-serviced prior to working their scheduled shift.
- The Minimum Data Set (MDS) nurse updated the care plan and Kardex to reflect the need for one on one supervision.
- Behavior monitoring has been ongoing with this resident but was updated to include the behavior of rummaging.
- The DON or Staff Development Nurse has assigned a staff member each shift to make rounds every 30 minutes to check that all carts in the facility are locked.
- The Director of Nursing, Staff Development Nurse or Registered Nurse Supervisor are assigned to audit the one on one supervision sheets on a daily basis for compliance with one on one supervision of Resident #1.
- AD HOC Quality Assurance (QA) meeting held to review plans for removal of Immediate Jeopardy (IJ) tag.
Failure to Notify Resident Representative of Change in Condition
Penalty
Summary
The facility failed to notify the resident representative (RR) of a severely cognitively impaired resident about a change in the resident's condition. The deficiency involved a failure to communicate the presence of scratches on the resident's chest, which were noted during a body audit conducted by the Director of Nursing (DON) on a specific date. Despite the facility's policy requiring notification of family or resident representatives about changes in a resident's condition, the DON forgot to inform the RR about the scratches. The resident, who had been admitted to the facility with diagnoses including Chronic Leukemia, Type 2 Diabetes, Chronic Kidney Disease, and Unspecified Dementia, had a Brief Interview for Mental Status (BIMS) score indicating severe cognitive impairment. The RR discovered the scratches during a visit and subsequently filed a grievance due to the lack of notification. The grievance led to an acknowledgment from the DON that the scratches were noted but not communicated to the RR, which was a deviation from the facility's policy.
Failure to Report Resident-to-Resident Non-Consensual Contact
Penalty
Summary
The facility failed to report an allegation of resident-to-resident non-consensual sexual contact to the State Agency within the required timeframe. The incident involved two residents with dementia, where one resident was observed by an LPN to have inappropriately touched another resident on two separate occasions. The LPN documented these observations in the residents' behavioral progress notes and informed the RN Supervisor. However, the RN Supervisor stated that she was only informed of verbal remarks and not the physical contact, which she would have reported to the DON if known. The Social Service Director became aware of the incidents during a Minimum Data Set assessment and reported them to the Interdisciplinary Team, including the Administrator and DON, three days after the incidents occurred. Despite this, the DON did not report the allegations to the State Agency or any other agency. The Administrator confirmed that no report was submitted and mentioned that they consult with corporate on potentially reportable incidents. The resident involved in the inappropriate behavior had a history of schizophrenia, vascular dementia with behavioral disturbances, and moderate cognitive impairment.
Failure to Secure Hazardous Chemicals and Supervise Resident
Penalty
Summary
The facility failed to ensure the environment was free from accident hazards and that residents received adequate supervision to prevent a resident from ingesting a cleaning solution. The incident involved a resident with wandering behaviors who retrieved a cleaning solution from an unsecured housekeeping cart. The facility's policy required hazardous chemicals to be locked when not in use and under direct control of facility personnel while in common areas, but this was not followed in this case. On the day of the incident, a housekeeper left her cleaning cart unlocked and unattended while cleaning a bathroom. The resident, known for wandering and taking unsecured items, accessed the cart and consumed a small amount of the cleaning solution. The Director of Nurses confirmed that the resident's nurse witnessed the ingestion and took immediate action by contacting the Nurse Practitioner and poison control for further instructions. Interviews with the housekeeping staff revealed that they were aware of the policy to keep carts locked and aligned with the room they were cleaning but failed to adhere to it. The resident involved had a history of dementia with behavioral disturbances, impulse disorder, and psychotic disorder with hallucinations, making him particularly vulnerable to such hazards. The facility's failure to secure hazardous chemicals and supervise the resident adequately led to this preventable incident.
Failure to Timely Manage and Treat Pain Complaints
Penalty
Summary
The facility failed to timely manage and treat complaints of pain for two residents when there was no licensed nurse available on their unit from approximately 7:00 PM on 3/22/24 until approximately 1:47 AM on 3/23/24. Resident #2 reported severe pain rated nine on a 0-10 pain scale to a CNA, who informed her that there was no nurse available to administer medication. Resident #2 had a physician order for Norco to be given every six hours as needed for pain, but she did not receive her medication until later that night, causing her to stay awake due to the pain. Resident #2 was cognitively intact with a BIMS score of 15 and had diagnoses including Type 2 diabetes and Peripheral autonomic neuropathy. Resident #4, who had undergone surgery and was experiencing surgical-related pain, also reported pain to a CNA on the evening of 3/22/24. The CNA informed Resident #4 that there was no nurse available to administer pain medication. Resident #4 rated her pain as 5 to 6 on a 0-10 pain scale. She had physician orders for multiple pain medications, including Acetaminophen, Hydrocodone-Acetaminophen, and Tramadol, to be given every six hours as needed. Resident #4 had a BIMS score of 12, indicating moderate cognitive impairment, and had diagnoses including Encounter for orthopedic aftercare following surgical amputation and Peripheral vascular disease. Interviews with staff revealed that the RN Supervisor did not visit the 500 Hall during her shift, and the LPN assigned to the 600 and 800 Halls did not attend to the 500 Hall residents. The LPN assumed that a Float Nurse would cover the 500 Hall, but the Float Nurse did not show up, and the On-Call Nurse did not respond to calls. The Director of Nurses confirmed that there was a break in staff communication, leading to the failure to monitor and administer medications to the residents on the 500 Hall for approximately six hours and 45 minutes. The Administrator was unaware of the staffing issue until inquiries were made by the State Agency on 4/01/24.
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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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