Pine Forest Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Jackson, Mississippi.
- Location
- 1116 Forest Avenue, Jackson, Mississippi 39206
- CMS Provider Number
- 255326
- Inspections on file
- 27
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Pine Forest Health And Rehabilitation during CMS and state inspections, most recent first.
A resident with paraplegia, reduced mobility, and intact cognition experienced a fall from bed with head impact in the evening, was found on the floor by CNAs, and was assisted back to bed under direction of an LPN without timely assessment or notification of the resident’s representative (RR). The resident reported the fall and head injury to a Wound Care Nurse the following morning, at which point the Unit Manager, DON, and Administrator were informed, and the RR was finally notified. Facility policies on resident rights and falls required prompt RR notification and documentation of who was notified and when, but there was no documentation of RR notification on the date of the fall, resulting in a deficiency for failure to immediately inform the RR of a significant change in condition.
A resident with paraplegia, reduced mobility, and intact cognition fell from bed in the evening, landing face-down on the floor and striking the head, as later reported by CNAs and the resident. An LPN directed CNAs to return the resident to bed, but no fall was documented, and no immediate vital signs, neuro checks, pain assessment, or body audit were performed during the evening or night shifts, despite facility policy requiring these actions for unwitnessed falls and head injuries. The resident reported the fall and forehead swelling to the Wound Care Nurse the next morning, at which point the Unit Manager and DON were notified, and the primary healthcare provider and resident representative were contacted. The DON and Administrator confirmed there was no contemporaneous documentation or appropriate assessment after the fall and that staff did not follow the facility’s fall policy or timely notification requirements.
A resident who was non-ambulatory and returning from dialysis sustained a scapular fracture and multiple rib fractures after a CNA failed to lock both wheelchair wheels during van loading, causing the wheelchair to roll off the lift platform. The resident fell onto the concrete driveway and required hospital evaluation and treatment. Staff interviews and facility policy review confirmed that proper safety procedures were not followed.
Two residents with significant cognitive impairments were not provided with the structured or individualized activities outlined in their care plans. Despite documented preferences for music and therapeutic engagement, both were observed spending long periods unengaged in the dayroom. Staff interviews confirmed a lack of follow-through on care plan interventions, and facility policy requiring adherence to care plans was not met.
Two residents with severe cognitive impairment were not provided with activities tailored to their needs and interests. Both were observed spending long periods without engagement or appropriate stimulation, despite staff acknowledging the lack of suitable activities and the facility's policy requiring individualized activity planning.
A newly admitted resident with dementia and altered mental status exited the facility unsupervised after a receptionist, unaware of her status, unlocked the front door. The resident was found in a busy intersection, requiring multiple staff to retrieve her. The incident occurred during shift change, and the resident had not yet been added to the wandering risk binder. This failure to supervise and secure the exit resulted in Immediate Jeopardy and Substandard Quality of Care.
A resident with dementia and altered mental status was able to exit the facility unsupervised after a receptionist, unaware of the resident's new admission status, released the front door lock. The resident was found in a public intersection, combative and seeking to go home. Staff interviews revealed gaps in communication and monitoring, and the resident's risk for wandering was not fully identified or addressed prior to the incident.
Staff failed to follow infection control protocols during care for two residents with indwelling devices. An LPN did not wear a gown while administering medication via PEG tube, and another LPN did not use a clean section of a washcloth for each wipe during suprapubic catheter care. Both actions were contrary to facility policy and infection prevention standards.
Two residents did not receive care as outlined in their care plans. One resident with incontinence and ADL deficits was found in heavily soiled linens without scheduled peri care, as confirmed by CNAs and the DON. Another resident, requiring two-person assistance for repositioning due to significant physical impairments, was turned by a single CNA, resulting in a fall. The MDS nurse confirmed that care plans are essential and must be followed by all staff.
A resident with a stage 4 sacral pressure ulcer and severe cognitive impairment did not receive thorough perineal care, as CNAs failed to clean the area properly before applying a new brief, leaving the resident soiled with urine and feces. Staff interviews and observations confirmed that perineal care was incomplete and not performed as required by facility policy.
A resident with a stage 4 sacral pressure ulcer did not receive peri-care before wound care was performed by LPNs, despite being found with heavily soiled linens and a saturated brief. Wound care was completed without addressing the soiling, and the resident reported infrequent changes and prolonged periods of wetness. The DON confirmed that peri-care should have been provided prior to wound care, in accordance with facility policy.
The facility did not maintain or monitor previously implemented QAPI interventions, resulting in repeated deficiencies related to staff not following a resident's care plan and improper infection control during PEG and suprapubic catheter care for two residents. These issues persisted despite being cited in a prior survey.
A resident with cognitive impairment and right hemiparesis was physically abused by a CNA, resulting in facial injuries. The CNA admitted to using force to prevent the resident from hitting her during perineal care. Despite the resident's injuries and his account of being hit, the facility's investigation did not substantiate the abuse allegation, citing the resident as the aggressor. This indicates a deficiency in the facility's adherence to abuse prevention protocols.
A resident with cognitive impairment and hemiparesis experienced physical force from a CNA during care, resulting in injuries. The CNA did not follow the resident's care plan, which instructed staff to stop and return if the resident became agitated. Despite the resident's aggressive behavior, the care plan's directives were not implemented, leading to the incident.
A resident with paraplegia and moderate cognitive impairment was injured during a transfer when a CNA attempted to use a mechanical lift without a second staff member, contrary to facility policy and lift instructions. The resident was left unattended in the lift sling, resulting in a fall and head injury requiring staples. The CNA had been trained on proper lift use, including the need for two staff members, but failed to ensure adequate assistance.
The facility failed to ensure call lights were within reach for two residents, both with severe cognitive impairments and dependent on staff for daily activities. Observations revealed call lights on the floor, out of reach, despite staff expectations for accessibility. Interviews confirmed the importance of call lights being within reach to ensure timely responses to residents' needs.
The facility failed to acknowledge and resolve grievances promptly, affecting two residents. One resident's concerns were not addressed until family intervention, despite having no cognitive impairment. Another resident's family reported issues with care quality, but received no follow-up, despite multiple communications with staff. The facility's grievance logs did not document these issues, and concerns raised in Resident Council meetings were not treated as grievances, leading to unresolved issues and lack of communication.
The facility failed to implement individualized ADL care plans for four residents, resulting in inadequate personal hygiene care. Observations revealed untrimmed fingernails and toenails with a dark substance beneath them, and unwanted facial hair not addressed during daily care. Interviews with staff indicated a lack of communication and adherence to care plan interventions, despite care plans being accessible through facility software and kiosks. The DON and Administrator confirmed that ADL care should align with resident preferences and care plans.
The facility failed to provide necessary grooming services for four residents, including nail care and facial hair removal. Observations showed residents with long, unclean nails and unwanted facial hair, despite being dependent on staff for ADLs. Interviews revealed inconsistencies in staff responsibilities for grooming tasks, leading to unmet hygiene needs.
The facility's QAPI committee failed to address deficiencies related to comprehensive care plans for ADL care and grooming for dependent residents. Despite policies for improvement, the committee did not effectively implement measures to correct these issues, leading to re-cited deficiencies. The Administrator noted that the facility may not have monitored enough residents to ensure adequate grooming care.
Failure to Promptly Notify Resident Representative After Fall With Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative (RR) of a change in condition following a fall, as required by facility policy and resident rights. Facility policies on Resident Rights & Dignity Management and Falls Standard state that residents and/or their designated representatives must be fully informed of changes in medical or health status, including incidents and accidents, and that documentation must include who was notified and when. The Falls Standard further specifies that family is to be notified of a fall event. These policies were not followed for one sampled resident who experienced a fall with head impact. Resident #1, admitted with diagnoses including paraplegia, reduced mobility, and lack of coordination, was non-ambulatory and dependent for transfers. The resident’s Quarterly MDS showed a BIMS score of 14, indicating cognitive intactness. On the evening of 12/27/25, CNAs reported finding the resident lying on her face on the floor next to her bed and, under the direction of an LPN, assisting her back into bed. The resident later reported that she had fallen from bed while reaching for something on the floor and had bumped her head. There was no documentation that the RR was notified at the time of the fall, and the resident did not receive assessment and treatment until the following morning. On the morning of 12/28/25, the resident informed the Wound Care Nurse that she had fallen the previous evening, hit her head on the floor, and had a raised, tender area on her right forehead. The Wound Care Nurse then notified the Unit Manager, who in turn notified the DON and Administrator. The facility’s incident report and investigation documented the fall as an unwitnessed event reported by the resident, with RR notification recorded at 9:46 AM on 12/28/25. The RR stated she was not notified of the fall until after 9:30 AM the following morning and expressed disapproval and disappointment with the delay, noting she observed swelling on the resident’s forehead. The Administrator confirmed there was no documentation of RR notification on the date of the fall, establishing that the facility failed to promptly notify the RR of the resident’s change in condition as required by policy and resident rights.
Failure to Assess, Monitor, Document, and Report an Unwitnessed Fall With Head Impact
Penalty
Summary
The deficiency involves the facility’s failure to follow its own fall policy and adequately assess, monitor, and report an unwitnessed fall with head impact for one resident. The facility’s Falls Standard policy required that when a resident is found on the floor, staff must investigate the reason for the fall, obtain vital signs while the resident is on the ground, perform neurological checks for unwitnessed falls or head injuries, and complete fall-related documentation including a Fall Risk Assessment, incident report, and post-fall investigation. The policy also required neurological assessments every 15 minutes for 2 hours, every 30 minutes for 2 hours, and then every shift for 72 hours, as well as timely notification of the resident’s primary healthcare provider, resident representative, DON, and others as appropriate. These procedures were not followed after the resident’s fall on the evening of 12/27/25. Resident #1 was admitted with diagnoses including paraplegia, reduced mobility, and lack of coordination, and was documented as non-ambulatory and dependent for transfers. The resident was cognitively intact with a BIMS score of 14. On the evening of 12/27/25, the resident fell from the bed while reaching for something on the floor and struck her head, resulting in a bump and swelling on the right forehead. CNA #1 and CNA #2 reported finding the resident lying on her face on the floor next to the bed at approximately 7:45–7:48 PM, and stated that an LPN instructed them to assist the resident back into bed. There was no documentation of a fall, no recorded vital signs taken while the resident was on the floor, and no neurological checks, pain assessments, or body/skin audits performed or documented during the 3:00 PM–11:00 PM or 11:00 PM–7:00 AM shifts following the incident. The fall was not reported to supervisory staff, the primary healthcare provider, or the resident representative at the time it occurred. The resident later informed the Wound Care Nurse on the morning of 12/28/25 that she had fallen the previous evening, hit her head on the floor, and had swelling and tenderness above the right eye. Only after this self-report were the Unit Manager, DON, primary healthcare provider, and resident representative notified, and an incident report and investigation initiated. The resident representative stated she was not notified of the fall until the following morning and expressed disapproval and disappointment with the delay in notification, noting that the resident had a bump on her forehead and had not received assessments or treatment until the next day. The Administrator and DON confirmed there was no documentation of the fall or appropriate assessment or evaluation on the evening and night shifts, and that nursing staff did not follow the facility’s fall policy, including required assessments, monitoring, documentation, and timely notification of the resident representative and primary healthcare provider. The DON acknowledged that the correct procedure after a fall included immediate assessment, body/skin audit, pain assessment, initiation of neurological checks and vital sign monitoring for 72 hours, and prompt notification of the primary healthcare provider, resident representative, DON, Administrator, and ambulance if needed. The DON also confirmed that failure to report incidents and provide assessments and care according to the fall policy could result in the resident having unrelieved pain, complications, or negative unidentified results from falls. Interviews with the Unit Manager and Wound Care Nurse further confirmed that falls were to be reported and documented on the 24-hour report, with incident reports and ongoing assessments, and that resident representatives should be notified right away as a change of condition. Despite these established policies and staff knowledge, the required post-fall assessments, monitoring, documentation, and timely notifications were not carried out following Resident #1’s unwitnessed fall with head impact on the evening of 12/27/25.
Failure to Secure Wheelchair During Van Loading Results in Resident Injury
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) failed to properly secure a resident's wheelchair during the process of loading the resident onto a facility van lift platform. The facility's policy required that both wheelchair brakes be locked before operating the lift, but the CNA only locked one wheel. As a result, the wheelchair rolled backward off the lift platform while the resident was seated, causing the resident to fall onto the concrete driveway. The resident involved had a history of hemiplegia affecting the right dominant side and was non-ambulatory, requiring a wheelchair for mobility. At the time of the incident, the resident was returning from a dialysis appointment and was cognitively intact. The fall resulted in the resident sustaining a scapular fracture and multiple rib fractures, as confirmed by hospital imaging. The resident reported pain and was later transported to an acute care hospital for further evaluation and treatment. Interviews with facility staff and the resident confirmed that the CNA did not follow the required safety procedures for securing the wheelchair. The CNA admitted to failing to lock both wheels, and staff interviews corroborated that the incident occurred while the lift was on the ground. The facility's investigation concluded that the CNA's failure to adhere to established protocols directly led to the resident's fall and subsequent injuries.
Failure to Implement Individualized Activity Care Plans for Two Residents
Penalty
Summary
Surveyors found that the facility failed to implement individualized care plans for two residents regarding participation in structured activities. Observations over two days showed both residents spending extended periods in the dayroom without engagement in any planned or structured activities, despite care plans specifying their enjoyment of music and the need for therapeutic activities. One resident, who is nonverbal with a history of traumatic brain injury and a BIMS score of 0, was observed sitting in a Geri-chair, not participating in group activities such as music therapy or movies as outlined in her care plan. The other resident, diagnosed with dementia and psychosis and also with a BIMS score of 0, was similarly left unengaged, seated with her back to the television and not included in activities appropriate to her needs. Interviews with staff, including a CNA, the Activities Director, the DON, and an LPN responsible for care planning, confirmed that the residents were not provided with the individualized activities specified in their care plans. Staff acknowledged oversights and a lack of follow-through, with the Activities Director admitting to not bringing the resident to a music activity and the DON confirming the absence of stimulating activities for the second resident. Facility policy requires that residents receive services and items included in their care plans, but this was not followed for these two residents, resulting in a failure to meet their psychosocial needs as documented.
Failure to Provide Individualized Activities for Residents with Cognitive Impairment
Penalty
Summary
The facility failed to provide activities designed to meet the physical and mental needs and interests of two residents, as required by facility policy and resident rights. Observations revealed that both residents spent extended periods in the dayroom without any structured or care-planned activities. One resident, who is nonverbal and has a history of traumatic brain injury with a BIMS score of 0, was observed sitting in a Geri-chair, not participating in activities such as music or bingo, which staff acknowledged were not appropriate for her. The other resident, diagnosed with dementia and psychosis and also with a BIMS score of 0, was repeatedly observed sitting alone with her back to the television and no engagement in any activities. Interviews with staff, including a CNA, the Activities Director, the DON, and the Administrator, confirmed the lack of individualized activities and engagement for these residents. Staff admitted to oversights in including the residents in suitable activities and acknowledged that the activities provided, such as bingo, were not appropriate for their cognitive abilities. The DON specifically recognized the need for more stimulating activities for one resident and cited a lack of staff follow-through. Facility policy requires support of resident choice and activities consistent with assessments and care plans, which was not observed in these cases.
Resident Elopement Due to Failure in Supervision and Door Security
Penalty
Summary
A deficiency occurred when a newly admitted resident with diagnoses of unspecified dementia and altered mental status was able to exit the facility unsupervised and unmonitored. The resident left through the front door after the receptionist, not recognizing her as a resident, unlocked the door. No staff or visitors were present to intervene as the resident exited. The resident was subsequently found sitting on the back of a trailer attached to a pickup truck in the middle of a busy intersection approximately 600 feet from the facility, surrounded by several cars. Multiple staff members, including nursing and administrative personnel, responded to retrieve the resident, who was combative and resistant to returning to the facility. Interviews with staff revealed that the incident occurred during a shift change, and several staff members, including LPNs, the DON, ADON, and the Administrator, did not witness the resident leaving the building but responded after hearing staff yelling about the resident's elopement. The receptionist admitted to unlocking the door for the resident, stating she did not recognize her due to the resident's recent admission. The admissions coordinator and nursing staff did not identify any significant concerns in the preadmission documents, although the resident's daughter had mentioned increased difficulty managing her at home. The social services director had not yet updated the wandering risk binder to include the new resident, as she was off work at the time of admission and had planned to complete the assessment the following day. The facility's policy on abuse, neglect, and exploitation prohibits acts of neglect, defined as the failure to provide necessary services to avoid physical harm. The resident's elopement and exposure to a hazardous situation in a busy intersection constituted a failure to protect her from neglect. The initial assessment of the resident upon return revealed no injuries, but the event was determined to be Immediate Jeopardy and Substandard Quality of Care due to the risk of serious harm.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Risk Assessment
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision, monitoring, and preadmission risk assessment to prevent a resident from exiting the facility unsupervised and without staff awareness or intervention. The resident, who had been admitted the previous day with diagnoses including unspecified dementia and altered mental status, was able to leave the building through the front door after the receptionist released the door lock. The receptionist did not recognize the resident as a new admission and allowed her to exit unaccompanied. The resident was later found approximately 600 feet from the facility, seated on a trailer in a public intersection surrounded by traffic, and was described as combative and yelling that she wanted to go home. Interviews with staff revealed that several employees, including LPNs, the DON, the Administrator, and CNAs, responded after hearing shouting and ran outside to retrieve the resident. None of the staff interviewed witnessed the actual elopement, only the aftermath. The receptionist confirmed that she had unlocked the door for the resident, not realizing she was a new admission, and the resident's representative stated she had told the receptionist to let the resident out, also not realizing the resident was new. The facility's policy required all residents to be assessed for wandering risk prior to or upon admission, but the assessment did not identify the resident's history of wandering as reported by the family. Further review indicated that the facility's process for identifying and monitoring residents at risk for wandering was not fully implemented for this resident. The Social Services Director had not yet added the resident to the wandering binder due to being off work at the time of admission, and the nurse who completed the assessment attributed the resident's confusion to a urinary tract infection, not being aware of the family-reported wandering history. The lack of effective communication and monitoring allowed the resident to exit the facility unsupervised, resulting in a situation determined to be Immediate Jeopardy and Substandard Quality of Care.
Failure to Follow Infection Control Protocols During Device Care
Penalty
Summary
The facility failed to adhere to infection prevention and control protocols during care for two residents with indwelling medical devices. In one instance, an LPN administered medication via a percutaneous endoscopic gastrostomy (PEG) tube without donning a gown, as required by the facility's Enhanced Barrier Precautions (EBP) policy and CDC recommendations. The LPN acknowledged she was trained on EBP and recognized the omission, and both the Infection Preventionist and Director of Nursing confirmed that a gown should have been worn to prevent potential transmission of infection. In another instance, an LPN provided suprapubic catheter care to a resident but did not follow the facility's policy for cleaning the catheter site. The LPN used the same section of a washcloth in a circular motion multiple times before flipping to a clean section, rather than using a clean section for each wipe as required. The LPN, Infection Preventionist, and Director of Nursing all confirmed that this technique could transfer bacteria and increase the risk of infection. Both residents involved had relevant medical conditions requiring these devices and care procedures.
Failure to Implement Comprehensive Care Plans for Two Residents
Penalty
Summary
The facility failed to implement comprehensive care plans for two residents, resulting in unmet care needs. For one resident with bladder incontinence and an ADL self-care performance deficit, the care plan required incontinence care every two hours and as needed, with total assistance to keep the skin clean and dry. However, during an observation, the resident was found wearing a heavily soiled brief, turn pad, and draw sheet, all soaked with urine and emitting a putrid odor. Both CNAs interviewed confirmed that the care plan was not followed, and the resident had not received peri care as scheduled. The DON also confirmed that leaving a resident unclean and heavily soiled with urine increases the risk of infection and that peri care should be performed every two hours. Another resident with a self-care performance deficit required two staff members to assist with repositioning and turning in bed, as documented in the care plan. Despite this, a CNA repositioned the resident alone at the resident's request, resulting in the mattress sliding and the resident falling onto the floor. The CNA acknowledged that the care plan specified two-person assistance and admitted fault for not seeking help. The resident's medical history included Guillain-Barre Syndrome, paraplegia, restlessness, agitation, lack of coordination, and muscle weakness, and the resident was cognitively intact according to the most recent assessment. The MDS nurse confirmed that care plans are essential for determining and meeting residents' needs and should be followed by all staff.
Failure to Provide Adequate Perineal and Incontinent Care
Penalty
Summary
Certified Nursing Assistants (CNAs) failed to provide appropriate perineal care to a resident with a stage 4 sacral pressure ulcer and severely impaired cognition. During an observation, a CNA applied a clean brief without thoroughly cleaning the resident, as evidenced by repeated wipes that continued to show brown residue. Both the assisting CNA and the CNA performing care acknowledged that the cleaning was incomplete and that proper procedure was not followed. The Director of Nursing confirmed that perineal care should continue until the area is clean and that a clean wipe should be used each time. Further observations revealed that the resident was left heavily soiled with urine and feces, with soiled linens emitting a putrid odor. Interviews with staff confirmed that the resident was not properly cleaned and that perineal care had not been performed as scheduled. The resident, who is dependent for hygiene and toilet care, was not assigned to the CNA who provided care, and there was no documentation of refusal or reassignment. The facility's policy requires perineal care to maintain cleanliness and prevent infection, but this was not adhered to in the care of this resident.
Failure to Provide Proper Wound Care and Hygiene Prior to Dressing Change
Penalty
Summary
A deficiency occurred when wound care for a resident with a stage 4 sacral pressure ulcer was not performed in accordance with facility policy and infection control standards. During an observed wound care procedure, LPNs removed a wound vacuum and dressing from the resident while the resident's bed linens and brief were heavily soiled with yellow and brown urine. Peri-care was not performed prior to the wound care, and the LPN acknowledged not noticing the soiled condition until after the procedure was completed. The wound care nurse confirmed that wound care was initiated despite the resident being visibly soiled and that peri-care is typically provided beforehand with CNA assistance. The resident, who has severe cognitive impairment, reported being changed only once at night and remaining wet for long periods, with staff not checking on her during the night. The Director of Nursing confirmed that peri-care should have been completed before wound care and that failure to do so could lead to contamination and further skin breakdown. Facility policy requires dressing changes to be performed as ordered and infection control policies to be followed to prevent contamination in individuals with pressure ulcers.
Failure to Sustain QAPI Oversight for Care Plan and Infection Control Deficiencies
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to maintain and monitor implemented procedures and interventions that were put in place to address previously identified deficiencies. Specifically, the committee did not sustain effective oversight for two deficiencies originally cited in December 2023: failure to follow a resident's care plan and improper infection control practices. Record reviews and interviews confirmed that these deficiencies persisted during the current survey, indicating that the corrective actions previously established were not maintained or monitored as required by the facility's own QAPI policy. For the care plan deficiency (F656), a Certified Nursing Assistant did not follow the comprehensive care plan when repositioning a sampled resident. Regarding infection control (F880), observations revealed that staff failed to prevent the potential spread of infection during PEG care for one resident and suprapubic catheter care for another, as noted in two out of five care observations. These findings were corroborated by record reviews, interviews, and policy reviews, confirming that the same issues identified in the prior survey were still present.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by a Certified Nurse Aide (CNA). The incident involved a cognitively impaired resident with right hemiparesis, who was found with purplish-red discoloration under the right eye, abrasions on the nose, and a hematoma on the forehead. The CNA admitted to using physical force on the resident's left arm and face to prevent the resident from hitting her. The facility's policy on abuse prevention was not adhered to, as the CNA did not leave the room when the resident resisted care, which is against the facility's protocol. The incident occurred when the CNA attempted to provide perineal care to the resident, who was reportedly resistant and aggressive. The CNA applied pressure to the resident's arm and face, resulting in injuries. Despite the resident's cognitive impairment, he communicated that the CNA hit him, and this was corroborated by his physical injuries. The facility's investigation concluded that the abuse allegation was unsubstantiated, citing the resident as the aggressor, but the evidence of physical injuries and the CNA's admission of using force contradict this conclusion. Interviews with other staff and the resident's roommate revealed inconsistencies in the accounts of the incident. The roommate heard a loud pop and commotion but did not witness any hitting. Other CNAs and the LPN noted the resident's injuries and his frightened demeanor after the incident. The facility's failure to substantiate the abuse allegation despite the evidence suggests a deficiency in their investigation process and adherence to abuse prevention protocols.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to implement comprehensive care plan interventions for a resident with cognitive impairment and right hemiparesis. During an incident, a CNA used physical force on the resident, resulting in purplish-red discoloration under the right eye, abrasions on the nose, and a hematoma on the forehead. The care plan for the resident, which was supposed to guide staff in handling the resident's behavior during care, was not followed. The plan included directives to use simple communication and to stop and return if the resident became agitated. The incident occurred when the CNA attempted to change the resident's brief, and the resident became aggressive, swatting at the CNA. Despite the care plan's instructions to stop and return later if the resident became agitated, the CNA continued to apply pressure to the resident's functional arm and used force on the resident's face. The resident, who had a BIMS score indicating severe cognitive impairment, was dependent on staff for toileting hygiene and was always incontinent of urine. Interviews with facility staff, including the LPN responsible for MDS and care planning, confirmed that the CNA did not follow the care plan. The Director of Nursing also acknowledged that the CNA should have left the room and returned later to provide care, as per the care plan. The facility's investigation concluded that the allegation of abuse could not be substantiated because the resident was the aggressor, but the care plan was not implemented as required.
Failure to Secure Resident in Mechanical Lift Leads to Injury
Penalty
Summary
The facility failed to secure a resident in a mechanical lift and provide necessary supervision during a transfer, resulting in a laceration that required staples and an Emergency Department visit. The incident involved a resident with paraplegia and moderate cognitive impairment, who was dependent on staff for bed-to-chair transfers. On the morning of the incident, a CNA attempted to transfer the resident using a mechanical lift without the assistance of a second staff member, as required by the facility's policy and the lift manufacturer's instructions. The CNA left the resident suspended in the lift sling unattended while she went to the door to call for help, during which time the resident slid out of the sling and fell, sustaining a head injury. Interviews with facility staff, including the CNA involved, revealed that the CNA was aware of the requirement for two staff members to assist with such transfers and had received training on the use of mechanical lifts. The CNA confirmed that other staff were available to assist but she was the only one present in the room at the time. The Director of Nursing confirmed that the investigation determined the fall was due to the CNA's failure to ensure adequate staff were present for a safe transfer. The facility's Staff Educator emphasized that training included the importance of not leaving residents unattended in a lift.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents, leading to a deficiency in accommodating the needs and preferences of these residents. Resident #3, who was observed awake and resting in bed, had her call light on the floor by her bed. She was unable to locate it despite being able to use it. Resident #3 had a severe cognitive impairment with a BIMS score of 6 and was dependent on staff for all activities of daily living. Similarly, Resident #6 was found with her call light coiled up on the floor at the end of her bed, out of reach. She also had a severe cognitive impairment with a BIMS score of 7 and required staff assistance for daily activities. Interviews with facility staff, including CNAs and an LPN, confirmed that call lights were expected to be within reach of residents to ensure timely responses to their needs. The Director of Nurses and the Administrator both expressed expectations that call lights should be accessible to residents and answered promptly. Despite these expectations, the observations of the call lights being out of reach for Residents #3 and #6 indicate a failure to adhere to the facility's policy and ensure the safety and well-being of the residents.
Failure to Address and Communicate Grievances
Penalty
Summary
The facility failed to acknowledge and resolve grievances promptly, as well as communicate progress toward resolution with residents and their families. This deficiency was identified through interviews, record reviews, and policy reviews, affecting two of the seven sampled residents. The facility's policy on grievances, revised in January 2025, outlines that the Administrator is responsible for the Grievance Program, with Social Service staff designated as the Grievance Official. However, the facility did not adhere to its policy, as grievances were not documented or resolved in a timely manner, and there was a lack of communication with the residents and their families regarding the status of their grievances. Resident #2 reported concerns in December 2024 to the facility administration, which were not addressed until the resident's family intervened. The family member of Resident #2 attended a care conference to discuss these concerns, considering it an official grievance, but was uncertain about the facility's definition of an official grievance. The resident had a BIMS score of 15, indicating no cognitive impairment, and was admitted to the facility in February 2024 with a diagnosis of paraplegia. Resident #3's family expressed concerns about the quality of care, including issues with linens, the resident being left wet, food on clothes and bedding, and falls. Despite multiple communications with staff, including the ADON, DON, Administrator, and Social Worker, the family did not receive follow-up on their grievances. The resident, admitted in November 2024 with a diagnosis of cerebral infarction, had a BIMS score of 6, indicating severe cognitive impairment. The facility's grievance logs from October to December 2024 did not document these grievances, and concerns raised in Resident Council meetings were not treated as grievances, leading to unresolved issues and a lack of follow-up communication.
Failure to Implement Individualized ADL Care Plans
Penalty
Summary
The facility failed to implement individualized care plans for Activities of Daily Living (ADL) care related to personal hygiene for four residents. Observations and interviews revealed that residents had untrimmed fingernails and toenails with a dark brownish substance beneath them, indicating inadequate grooming. One resident expressed dissatisfaction with the length of their fingernails, stating they were unable to trim them independently and had not been offered assistance by staff. Another resident was observed with unwanted facial hair, which they were unable to remove themselves, and it was confirmed that this should have been addressed during daily ADL care. Interviews with facility staff, including CNAs, LPNs, and the Director of Nurses, highlighted a lack of communication and adherence to care plan interventions. CNAs were unaware of how care plan interventions were communicated, relying on nurses for instructions. The care plans, which were accessible through facility software and wall-mounted kiosks, were not consistently followed, resulting in unmet personal hygiene needs for the residents. The Director of Nurses and the Administrator confirmed that ADL care, including grooming and removal of unwanted facial hair, should be provided according to resident preferences and care plans.
Inadequate Grooming Care for Residents
Penalty
Summary
The facility failed to ensure that dependent residents received necessary grooming services, specifically related to nail care and the removal of unwanted facial hair. Observations and interviews revealed that four residents had issues with inadequate grooming. Resident #1 had short, smooth fingernails with a dark substance beneath them, and the resident's representative noted incidents of inadequate grooming. Resident #5 had long fingernails with a dark substance beneath them and long, curved toenails. Both residents were dependent on staff for all activities of daily living (ADLs) and had cognitive impairments. Resident #6 had long fingernails with a brownish substance underneath and expressed a preference for shorter nails but was unable to trim them himself. The resident had no cognitive impairment and was dependent on staff for ADLs. Resident #7 had a thick patch of unwanted facial hair and expressed a dislike for it but was unable to remove it herself. The resident had moderate cognitive impairment and was also dependent on staff for ADLs. Interviews with staff revealed a lack of consistent grooming care, with CNAs and nurses not adequately addressing the residents' grooming needs. The facility's policy required staff to assist residents with bathing, nail care, and facial hair removal to maintain proper hygiene and prevent infections. However, staff interviews indicated a lack of clarity and responsibility regarding these tasks. The facility's Director of Nurses and Administrator acknowledged the importance of meeting residents' grooming needs for their physical and psychosocial well-being, but the observations and interviews highlighted a failure to consistently provide these services according to residents' preferences and care plans.
Failure in QAPI Committee Leads to Re-cited Deficiencies
Penalty
Summary
The facility failed to sustain an effective Quality Assurance and Performance Improvement (QAPI) committee, as evidenced by two re-cited deficiencies originally identified in December 2023. The deficiencies were related to the facility's inability to implement comprehensive care plans for Activities of Daily Living (ADL) care and ensure adequate grooming for dependent residents. During a complaint survey conducted in July 2024, it was observed that the facility did not provide necessary services to maintain adequate grooming, including the removal of unwanted facial hair and fingernail care, for dependent residents. The facility's Quality Assurance Committee did not effectively identify, develop, and implement measures to correct these issues or prevent the recurrence of deficiencies. Despite the facility's policy outlining the use of Root Cause Analysis and the 'Plan, Do, Study, Act' cycle for improvement, the committee failed to address and prioritize identified problems adequately. The Administrator acknowledged that while audit results were presented and reviewed in QAPI meetings, the facility may not have monitored a sufficient number of residents to ensure comprehensive grooming care, given the facility's size and census.
Latest citations in Mississippi
A resident with hemiplegia, hemiparesis, and cognitive impairment had a care plan directing staff to apply and remove a right ankle splint at specific times each day and to provide passive stretching to prevent decline in ROM. Observation found the splint not in use and lying on a chair, and the resident was unsure when it was last applied. A PTA reported the resident had developed foot drop and that the splint could no longer be applied without additional therapy, attributing this to the splint not being used daily as ordered. The DON confirmed that staff failed to follow the established care plan for splint application and ROM management.
A resident with hemiplegia and hemiparesis after a cerebral infarction, and severe cognitive impairment (BIMS 5), had physician and therapy orders for right-hand and right-ankle splinting with passive ROM to manage contractures and maintain ROM. Surveyors observed a foot splint lying unused and the resident’s right hand contracted into a fist without a hand roll. The resident could not recall when the foot splint was last applied and reported never having a hand roll. An LPN was unaware of the need for the splint and confirmed no hand roll was in use. Records showed the hand splint order was discontinued at the responsible party’s request due to pain, but OT was not notified and no alternative such as a hand roll was initiated. PT had documented improved ankle ROM and recommended a PODUS boot, while a PTA later reported the resident had developed foot drop related to the ankle splint not being applied as ordered. The DON confirmed that daily ankle splint orders existed and that the hand splint was discontinued without alternative interventions to prevent contracture.
The facility failed to protect resident narcotic medications from misappropriation when an LPN handed over a medication cart’s narcotic keys to an RN without performing required narcotic counts before and after the transfer, and the cart was later found unlocked in the nurses’ station. During the subsequent shift change count, staff discovered multiple missing doses of oxycodone-acetaminophen and hydrocodone-acetaminophen prescribed PRN for pain to four residents with conditions including dementia, COPD, dysphagia, and diabetic neuropathy. Review of individual controlled drug logs showed corrected balances to account for the missing tablets, confirming that controlled substances were unaccounted for during the period of unsecured cart access and improper key control.
Two ambulatory residents with dementia, severe cognitive deficits, and known wandering behavior, each wearing a wander guard bracelet, were able to exit through a unit door when a visitor held it open, despite the door alarm sounding and prior observations that they frequently walked together and approached doors. An LPN responded to the alarm and, along with other staff, initiated a search when the residents could not be found on the unit; staff ultimately located the residents across a four-lane highway and returned them to the building without injury. The incident occurred despite facility policies requiring use of a security system for residents unable to protect themselves from harm by wandering, and staff and leadership acknowledged that the residents had a history of walking the halls together and going to doors, and that increased monitoring and restricting visitor access to door codes could have prevented the elopement.
A cognitively impaired resident with dementia, agitation, and a history of wandering was previously assessed by the IDT as not being at risk for elopement and did not have elopement precautions in place. On one occasion, a visitor exited through the front door without realizing the resident followed outside, and staff later discovered the resident alone on the front porch after being missing for several minutes. An LPN and CNA participated in locating and returning the resident, and the incident revealed that supervision and elopement risk assessment were insufficient for this resident.
A resident with Type 2 DM and moderately impaired cognition had two unstageable heel DTIs documented on the MDS and physician orders for treatment to both heels, but the comprehensive care plan did not include any problem, goals, or interventions related to these pressure injuries. LPNs responsible for MDS and care plan completion acknowledged the omission and stated that although they periodically audit by comparing orders to the care plan, this situation was missed. The DON reported she expected the wound care nurse to update the care plan with new wound treatment orders, while an RN stated she could update interventions but had not been trained to create a new focused care plan and was unaware it was her responsibility to add the DTI treatment orders to the care plan.
A controlled substance prescribed for a cognitively intact resident with a left femur fracture was delivered and signed for by an LPN but was not entered on the narcotic accountability record or narcotic box package count and was later found to be missing. One LPN reported receiving the blister pack of thirty Hydrocodone/Acetaminophen 10-325 mg tablets from another LPN, placing it on the nurses’ station, and leaving the area, while both LPNs stated they were in the medication room as the medication remained unattended. The DON and Administrator confirmed that staff failed to secure the controlled medication as required by facility policy and that the missing tablets could not be located.
Surveyors found that staff failed to properly secure and store medications for two residents. For one resident, an LPN received a delivery of Hydrocodone-Acetaminophen, passed it to another LPN, and the controlled medication was left unattended at the nurses’ station instead of being immediately locked and entered into the narcotic count, after which it could not be located. For another resident, two bottles of Lorazepam oral concentrate, documented on the narcotic record and labeled to be protected from light and refrigerated, were observed stored in a locked medication cart rather than in the designated medication refrigerator, even though staff acknowledged knowing the manufacturer’s refrigeration requirement.
A resident with hemiplegia and hemiparesis following cerebral infarction was transferred by facility van to a psychiatric hospital for evaluation and was later determined by the facility to be discharged due to aggressive behavior and threats, with staff stating they could not meet the resident’s needs. The Administrator and Social Services Director communicated with the psychiatric facility and the resident’s family about finding alternative placement and informed the family the resident would not be allowed to return, but no formal involuntary discharge notice or written appeal rights were provided, and no physician discharge order was documented, contrary to facility policies requiring a completed transfer form and written notice of transfer/discharge with appeal information.
The facility did not adequately investigate, address, or resolve repeated grievances about food quality and temperature raised through Resident Council meetings. Over several months, residents reported that weekend meals were bad, food was consistently cold, beverages lacked sufficient ice, and breakfast items were hard or unpalatable. While limited steps such as using temperature-holding containers, sending trays out faster, and in-servicing dietary staff were noted, there was no documented monitoring, follow-up, or evaluation of effectiveness. Cognitively intact residents continued to report cold, poor-tasting food, and staff, including the Dietary Manager and Social Services, acknowledged awareness of the complaints without evidence of thorough follow-up or resolution.
Failure to Implement Care Plan for Ankle Splint and ROM Management
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan for contracture management and splinting to prevent decline in range of motion for one resident. The facility’s policy on prevention of decline in range of motion required that, based on the comprehensive assessment, the facility provide interventions, exercises, and/or therapy to maintain or improve ROM. The resident’s care plan, initiated on 8/1/25, identified an ADL self-care performance deficit related to stroke, hemiplegia, and immobility, placing the resident at risk for functional decline. The care plan interventions directed staff to apply a splint to the right ankle after breakfast, provide passive stretch to the right ankle after applying the splint, remove the splint at lunchtime, reapply the splint after supper with passive stretch, and remove the splint at bedtime. On observation, the resident’s ankle splint was not in use and was found lying in a chair in the resident’s room, and the resident was unsure when the splint was last applied. The PTA reported that the resident had developed foot drop and that the ankle splint could no longer be placed without additional therapy, confirming this was related to the splint not being applied daily as ordered. The DON stated that the care plan was used to inform staff how to care for the resident and verified that staff failed to follow the care plan when they did not apply the ankle splint. Record review showed the resident was admitted with hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, and an MDS assessment indicated a BIMS score of 5, reflecting cognitive impairment at the time of the deficiency.
Failure to Implement ROM and Splinting Orders Resulting in Contractures and Foot Drop
Penalty
Summary
The facility failed to provide ordered range of motion (ROM) and splinting interventions to prevent decline in ROM for a resident with hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side. The resident was admitted with these diagnoses and had physician orders and therapy recommendations for contracture management and splinting. An OT evaluation documented decreased ROM in the right upper extremity and recommended a resting hand splint and a restorative splint and brace program, with a subsequent OT evaluation recommending continuation of the contracture management and splinting program. A physician order directed staff to apply a right-hand splint after breakfast, provide passive stretch to the right elbow, wrist, and hand once daily, and remove the splint before dinner. Another physician order required application of a right ankle splint after breakfast and after supper with passive stretching following application. The facility’s own policy stated that residents without limited ROM should not experience a reduction in ROM unless clinically unavoidable. During observation, surveyors noted a foot splint lying unused in the resident’s chair and the resident’s right hand contracted into a fist without a hand roll in place. The resident reported not knowing when the foot splint was last applied and stated she had never had a hand roll. An LPN stated she did not know why the splint was in the room, believed the resident was not required to wear it, and confirmed the resident did not have a hand roll. Record review showed the right-hand splint order was discontinued at the responsible party’s request due to pain, but the OT reported she had not been notified of this discontinuation and stated a hand roll should have been initiated when the splint was stopped; she further stated the resident’s hand was now contracted into a fist. A PT discharge summary documented improved right ankle ROM with therapy and recommended a PODUS boot daily for up to five hours, while a PTA later reported the resident had developed foot drop and that the ankle splint could no longer be applied without additional therapy, confirming this was related to the splint not being applied daily as ordered. The DON verified that there were physician orders for daily ankle splinting and acknowledged that the right-hand splint was discontinued without alternative interventions to prevent contracture. The resident’s MDS showed a BIMS score of 5, indicating severe cognitive impairment.
Failure to Secure Narcotic Medications and Maintain Key Control
Penalty
Summary
The deficiency involves the facility’s failure to protect resident medications from misappropriation on one of four medication carts, resulting in missing controlled substances for four residents. The facility’s abuse, neglect, and exploitation policy defines misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings or money without the resident’s consent. On a specific date, during the 7:00 PM shift change narcotic count, staff identified that multiple doses of Percocet and Norco (hydrocodone-acetaminophen) were missing from the narcotic box on a single medication cart. Prior to this discovery, the assigned LPN had confirmed that the narcotic count was correct earlier in the day. The events leading to the deficiency included the LPN giving her medication cart narcotic keys to an RN while she left the area to perform a urine specimen collection. The LPN did not complete a narcotic count before or after transferring the keys, which was not in accordance with facility expectations for key control and chain of custody. When the LPN returned, she observed the medication cart in the nurses’ station and unlocked. The RN later confirmed that she had moved the cart into the nurses’ station but denied administering any medications during the time she had possession of the keys. During the subsequent 7:00 PM narcotic count, discrepancies were identified, and a search of the cart and nurses’ station did not locate the missing medications. Record review showed that four residents’ controlled medication logs required corrections to reflect missing tablets. One resident with dementia had an order for oxycodone-acetaminophen 5-325 mg every 12 hours as needed for pain; the narcotic log initially showed a remaining balance of 20 tablets after a documented administration, but was later corrected to 16 tablets to account for four missing tablets. A second resident with COPD had an order for oxycodone-acetaminophen 10-325 mg every eight hours as needed; the log was corrected from a remaining balance of five tablets to four, indicating one missing tablet. A third resident with dysphagia had an order for hydrocodone-acetaminophen 5-325 mg every 24 hours as needed; the log showed two tablets on hand after the resident returned from pass with no administrations documented, and was later corrected to zero, indicating two missing tablets. A fourth resident with type 2 diabetes mellitus with diabetic neuropathy had an order for hydrocodone-acetaminophen 7.5-325 mg every six hours as needed; the log was corrected from a remaining balance of eight tablets to seven, indicating one missing tablet. These discrepancies, combined with the unsecured cart and improper key transfer without counts, led to the determination that resident medications were not protected from misappropriation.
Failure to Prevent Elopement of Two Cognitively Impaired Wanderers
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent elopement for two residents with known wandering and elopement risk. Both residents were ambulatory, frequently walked throughout the facility together, and were known to staff as wanderers. Each resident had a diagnosis of dementia with severe cognitive deficits documented on their MDS assessments, and both had Wander/elopement alarms (wander guard bracelets) in place and used daily. The facility’s elopement/wandering policy stated that residents who are incapable of adequately protecting themselves and unable to determine when they are at risk for harm by wandering out of the facility should be placed on the resident security system to ensure safety. On the day of the incident, video surveillance later reviewed by the Administrator showed that a visitor entered an exit door on the B Unit at approximately 6:20 PM. The two residents at risk for elopement approached the door, and the visitor held the door open, allowing them to walk out of the building. The residents were wearing wander guard bracelets, and when they exited, the door alarm sounded. A nurse responded immediately to the alarm, exited the facility, and went down the walkway but did not see the residents. Staff were then alerted that the residents were missing, and a facility-wide search was initiated. Staff interviews and the facility’s documentation confirmed that the residents had previously been observed walking together throughout the facility and approaching doors, including the exit door involved in the incident. The Administrator reported that review of the video showed the two residents had approached the same door together two or three times prior to the elopement event. Despite their known patterns of wandering, severe cognitive impairment, and prior door-approach behavior, the residents were able to exit the facility unnoticed and unsupervised when the visitor held the door open. Staff ultimately located the residents across a four-lane high-capacity highway approximately 528 feet from the exit door and returned them to the facility, where body audits and assessments documented no injuries and intermittent confusion. The State Agency determined that the facility’s failure to provide adequate supervision to prevent the elopement of these residents, who had exhibited exit-seeking behaviors, placed them and other residents at risk for wandering and elopement in a situation likely to cause serious injury, harm, impairment, or death and cited the facility at F689 with Immediate Jeopardy and Substandard Quality of Care. The residents’ medical records and elopement reports documented that both were confused, had impaired memory, and were identified as wanderers. One resident had a BIMS score of 3 and the other a BIMS score of 0, both indicating severe cognitive deficits. Progress notes and elopement reports recorded that staff were notified when the residents were not on the unit and could not be located, that all staff were engaged in searching, and that the residents were ultimately found outside and assisted back into the building. Interviews with CNAs and an LPN described hearing a Code W called, running outside, and seeing the residents across the street after they had crossed the four-lane highway. The DON acknowledged that the residents were always walking in the facility, often together, and that they had wandered to doors and looked out, and agreed that increased monitoring and not allowing visitors to have door codes could have prevented the residents from leaving the building.
Removal Plan
- Conducted a facility search.
- Notified police of missing residents.
- Director of Nursing interviewed staff and residents.
- Notified the Medical Director and residents’ families.
- Administrator and Director of Nursing checked the wander guard system and facility doors to ensure proper functioning.
- Returned Resident #1 and Resident #2 to the facility.
- Completed an incident report.
- Completed an emergency Quality Assurance meeting.
- Initiated in-service training for all staff on the elopement policy, including a quiz to validate comprehension, and required staff (including contract staff) to complete the in-service before working their next scheduled shift, with Administrator monitoring compliance.
- Responded immediately to the door alarm by sending staff outside to locate residents and notifying additional staff to assist with the search.
- Reviewed video surveillance and confirmed a visitor held the door open allowing residents to exit.
- Held an emergency Quality Assurance meeting with the Medical Director, Director of Nursing, Administrator, Regional Director, involved staff, and Infection Preventionist.
- Changed the main entry door code.
- Verified entrance door signage was in place instructing not to allow residents to exit unaccompanied.
- Identified residents at risk for elopement and ensured elopement bracelets/transmitters were functional and doors were locking appropriately.
- Reviewed care plans for residents at risk for elopement.
- Completed body audits on Resident #1 and Resident #2.
- Conducted audits verifying resident location, elopement risk, and wander guard bracelet function.
- Medical Records updated care profiles of residents at risk for wandering.
- Assistant Administrator began audits of all doors for function and security.
- Provided in-services on elopement policy and procedure, Resident Rights, and incident and accident reporting.
- Conducted elopement drills on each shift.
- Implemented monitoring systems to sustain compliance.
- Director of Nursing to monitor wander guard system checks three times weekly for four weeks or until substantial compliance is attained.
- Director of Nursing to monitor resident behavior for elopement attempts via incident reports, observations, and communications weekly for four weeks or until substantial compliance is attained.
- Quality Assurance Committee to meet for four weeks to review compliance with the plan of action, then continue routine Quality Assurance monitoring if no further concerns are noted.
- Administrator to hold follow-up Quality Assurance meetings monthly for two months then quarterly thereafter to ensure sustained compliance.
- Updated entry screening kiosk to include an additional reminder and attestation to ensure resident safety, requiring visitors to agree that no resident comes in or out with them and triggering a staff alert if the visitor refuses.
- Administration spoke directly with the visitor to confirm visitor policies and procedures.
Elopement of Cognitively Impaired Resident Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent a cognitively impaired resident with a history of wandering from exiting the building unattended. The resident had diagnoses including dementia with agitation and a BIMS score of three, indicating severe cognitive impairment. The resident had been readmitted from a geriatric psychiatric hospitalization and was known by the DON to have a history of wandering. Despite this, the interdisciplinary team had previously determined that the resident was not at risk for elopement, and no elopement interventions such as a wander guard were in place at the time of the incident. On the day of the event, a visitor observed the resident standing near the front door and exited the facility without realizing the resident followed him outside. Staff later became aware that the resident was missing, and an LPN assisted in locating the resident. A CNA ultimately found the resident outside on the front porch and returned the resident to the facility, with the investigation determining the resident had been outside unattended for approximately five minutes. Staff interviews confirmed that the resident ambulated in the halls and had not previously attempted to exit the building, and that the resident was only reassessed and provided with a wander guard after the incident.
Failure to Care Plan for Pressure Injuries and Treatment Orders
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident with pressure injuries. The facility’s undated Care Plan Policy and Procedure stated that each resident’s care plan would remain current and inform staff of needs, strengths, goals, and approaches, and that a comprehensive person-centered care plan would be completed as needed. Record review showed that the resident was admitted with Type 2 Diabetes Mellitus with ketoacidosis without coma and, per the Discharge MDS with an ARD of 1/19/26, had a BIMS score of 12 indicating moderately impaired cognition. Section M of the MDS documented two unstageable pressure injuries presenting as deep tissue injuries (DTIs). Physician orders dated 12/10/25 directed treatment to right and left DTI pressure ulcers. Despite these documented DTIs and treatment orders, review of the resident’s comprehensive care plan revealed no care plan addressing the DTIs on the left and right heels, which was inconsistent with the physician orders. During interviews, two LPNs responsible for MDS and care plan completion confirmed that the care plan did not include the DTIs and stated that care plans are developed based on the MDS and physician orders, and that audits comparing orders to care plans are done periodically but this had been missed. The DON stated her expectation that the wound care nurse update the care plan with new wound care treatment orders. An RN reported she could update care plan interventions but had not been trained to develop a new focused care plan and had not added the physician’s DTI treatment orders to the care plan, and she was not aware it was her responsibility to do so.
Unsecured Controlled Medication Left Unattended and Lost
Penalty
Summary
The facility failed to prevent misappropriation of resident property when a controlled substance prescribed for a resident was left unattended and subsequently went missing. Facility policies on abuse and neglect defined misappropriation of resident property to include missing prescription medications or diversion of resident medications, including controlled substances, and the Medication-Controlled Substances policy required that only authorized licensed nursing and pharmacy personnel have access to controlled medications, that all controlled substances be stored in a locked cabinet or compartment, and that accurate accountability of all controlled drugs be maintained. Despite these policies, a pharmacy courier delivered thirty Hydrocodone/Acetaminophen 10-325 mg tablets for a resident with a left femur fracture, and the medication was signed for by an LPN but was not signed onto the narcotic accountability record, was not documented on the narcotic box package count, and could not be located. The resident, who was cognitively intact with a BIMS score of 15 and had a physician’s order for Hydrocodone/Acetaminophen, was later informed that the tablets delivered had been lost. Interviews revealed that one LPN received the blister pack of thirty Hydrocodone/Acetaminophen tablets from another LPN and placed it on the nurses’ station before leaving the area, leaving the controlled medication unattended. Both LPNs reported being in the medication room while the medication remained unattended at the nurses’ station. The DON reported being notified that the medication was missing and that an investigation confirmed the medication could not be located and had been left unattended, and the Administrator confirmed staff failed to ensure controlled medications were secured and accessible only to authorized personnel and that the facility was unable to determine the location of the missing medication.
Failure to Secure Controlled Drugs and Follow Refrigerated Storage Requirements
Penalty
Summary
The deficiency involves the facility’s failure to store and secure medications, including controlled substances, in accordance with professional standards and manufacturer instructions. For Resident #1, who was admitted with a left femur fracture and was cognitively intact with a BIMS score of 15, the physician ordered Hydrocodone-Acetaminophen 10-325 mg tablets. A facility investigation documented that a pharmacy courier delivered 30 tablets of this controlled medication, which were received and signed for by an LPN but were never documented in the narcotic count system and were later unable to be located. One LPN reported that after receiving the Hydrocodone-Acetaminophen from another LPN, she left the medication unattended at the nurses’ station while she completed other tasks instead of immediately securing it in the locked medication cart. The LPN who initially received the medication from the courier confirmed that the controlled medication had not been immediately secured in the locked cart following delivery. For Resident #3, who was admitted with heart disease and had a BIMS score of 10 indicating moderately impaired cognition, the physician ordered Lorazepam (Ativan) oral concentrate. The narcotic record showed that two containers of Lorazepam were signed into the narcotic record on the date of admission. Manufacturer prescribing information for the Lorazepam oral concentrate specified that it must be protected from light and stored refrigerated at 36–46°F. During a controlled drug count, surveyors observed that two bottles of Lorazepam oral concentrate for this resident were stored in the locked medication cart rather than in a refrigerator, despite the label instructions requiring refrigeration. One LPN confirmed the manufacturer’s storage instructions on the label but was unsure why the medication had not been refrigerated, and another LPN acknowledged awareness that the medication required refrigeration but confirmed it had been stored in the medication cart instead of the designated medication refrigerator.
Failure to Provide Required Involuntary Discharge Notice and Appeal Rights
Penalty
Summary
The deficiency involves the facility’s failure to provide required written notice of an involuntary discharge, including appeal rights, and to obtain a physician’s discharge order before refusing readmission of a resident following a hospital transfer. Facility policy titled “Transfer Form” stated that it is the policy of the facility to provide a completed and accurate transfer form to residents transferred or discharged from the facility, and the policy titled “Appealing a Transfer or Discharge Notice” stated that residents have the right to appeal transfer or discharge notices and, upon notice of transfer or discharge, will be provided with a statement of their right to appeal. Record review showed that the resident, admitted with hemiplegia and hemiparesis following cerebral infarction, left the facility by facility van to be admitted to a psychiatric hospital for evaluation. Progress notes dated several days after the transfer documented that the resident had been discharged from the facility due to aggressive behavior and that, per conversation with the psychiatric hospital, the Administrator and Social Services Director would assist in finding alternative placement and home health if needed. Documentation further indicated that, due to threats made, the facility stated it was unable to meet the resident’s needs and communicated with the resident’s family that the resident would not be allowed to return. During interview, the Administrator confirmed that neither the resident nor the family was provided a formal involuntary discharge notice or information on appeal rights and that no physician order for discharge could be located, acknowledging that the formal notice, appeal rights, and physician order should have been obtained prior to discharge.
Failure to Investigate and Resolve Ongoing Food-Related Grievances
Penalty
Summary
The facility failed to ensure that grievances voiced through the Resident Council regarding food quality and temperature were thoroughly investigated, addressed, and resolved. Resident Council minutes over multiple months documented repeated complaints that weekend food was "bad," tasted sweet, and that food was cold by the time it reached residents. Additional concerns included insufficient ice in water and tea, hard breakfast biscuits and toast, and cold grits. Although the facility’s grievance policy stated that residents and families could voice grievances without reprisal and that the facility would make prompt efforts to resolve grievances, there was no documentation that the initial complaint about weekend food quality was addressed, and subsequent complaints continued without evidence of thorough investigation or resolution. Resident Council Department Response Forms showed limited actions, such as placing food in containers to maintain temperature, conducting an in‑service for dietary staff, sending food out faster, and instructing staff to pass trays promptly, but there was no documentation of monitoring, follow‑up, or evaluation of whether these measures were effective. Residents interviewed, all cognitively intact per their MDS BIMS scores, consistently reported that the food remained cold and did not taste good, with one resident noting that staff would reheat food only if requested. The Dietary Manager acknowledged awareness of the complaints and stated he had spoken with weekend staff and made changes like replacing tray carts and providing guidance on food preparation, but confirmed there was no documentation of ongoing monitoring or additional interventions. Social Services and the Administrator both acknowledged awareness of the complaints and that additional follow‑up and resolution efforts should have occurred, yet no evidence of such follow‑up was present in the records.
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