Pleasant Hills Community Living Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Jackson, Mississippi.
- Location
- 1600 Raymond Rd, Jackson, Mississippi 39204
- CMS Provider Number
- 255112
- Inspections on file
- 26
- Latest survey
- February 23, 2026
- Citations (last 12 mo.)
- 11 (1 serious)
Citation history
Health deficiencies cited at Pleasant Hills Community Living Center during CMS and state inspections, most recent first.
A resident with COPD, heart failure, rheumatoid arthritis, moderate cognitive impairment (BIMS 9), and wheelchair dependence was transported by facility staff to an outside medical appointment when the wheelchair was not properly secured in the facility van. CNAs reported using the van’s securement system but did not use any checklist to verify correct application; during transit they heard a noise and found the resident on the van floor with the wheelchair on its side and the seatbelt no longer in place. The resident reported hitting the head and having head pain. The facility’s investigation and QAPI review determined that the wheelchair straps had not been appropriately placed to firmly secure the chair, while the maintenance review found the securement equipment itself intact and functioning. The resident was evaluated in a hospital ED for fall and head injury and treated with an over-the-counter analgesic after imaging showed no new diagnoses.
A resident with moderate cognitive impairment and a history of depression and falls exited the facility unsupervised after staff failed to intervene or follow elopement prevention procedures. The resident was outside for over 20 minutes and found 0.4 miles away, highlighting a lapse in supervision and adherence to facility policy.
Two residents with a history of aggression toward each other were involved in multiple physical altercations, resulting in injury and pain requiring medication. Despite staff awareness and attempts at monitoring and room changes, the residents continued to seek each other out, and effective interventions such as one-on-one supervision were not implemented. The facility did not ensure a safe environment free from abuse, as required by policy.
A resident with severe cognitive impairment and an indwelling urinary catheter was observed with the catheter collection bag visible from the hallway, as the privacy cover was left unsnapped and failed to conceal the bag or its contents. The facility's policy required the use of a privacy bag to preserve dignity, but this was not followed, as confirmed by the DON.
The facility discontinued the use of disposable premoistened cleansing cloths for several residents with wounds or fragile skin, despite previously informing residents and staff that these would be provided for those with such needs. Multiple residents and their families reported dissatisfaction with the alternative products, describing them as rough, inadequate, and leading to postponed or interrupted care. Medical records confirmed that the affected residents had significant medical conditions and required daily wound care, yet the facility did not supply the preferred cleansing cloths.
Two residents dependent on wheelchairs experienced discomfort and safety concerns due to damaged or unrepaired wheelchair armrests, while other residents did not receive timely personal hygiene care because of a lack of clean linens and inadequate cleansing supplies. Staff reported that care was postponed or interrupted, and residents and families expressed dissatisfaction with the quality and timeliness of care provided.
A facility did not report an allegation of resident-on-resident physical abuse to the State Agency within the required timeframe, despite staff witnessing and internally investigating the incident. Multiple staff, including an LPN, RN, and the Administrator, were aware of the event, but the Administrator chose not to report it due to ongoing incidents between the two residents and a denial from the alleged victim. Both residents had relevant medical histories and varying cognitive status, and the facility did not implement additional supervision at the time.
Two residents were observed with excessively long and dirty fingernails, and one with long toenails, despite expressing a desire for nail care. Both had medical conditions requiring assistance, and staff confirmed that nail care was part of ADL responsibilities and that supplies were available, but the care was not provided as required.
A resident with multiple diagnoses, including muscle weakness and altered mental status, experienced a fall that was documented in progress notes, but staff failed to complete an incident report, conduct follow-up monitoring, or provide required documentation. Interviews with LPN, staffing coordinator, and DON revealed lack of awareness or recall of the incident, and the administrator was unable to locate any related documentation, despite facility policy requiring assessment and documentation after falls.
A resident with no cognitive impairment was found to have two vials of Ipratropium-Albuterol Inhalation Solution, one opened and one unopened, left unsecured on the overbed table in their room. Facility policy requires medications to be stored securely and only allows bedside storage with a prescriber's written order, which was not present. The DON and Administrator were unaware of the unsecured storage, and there was no individual medication storage cabinet in the room.
The facility did not include required information about staffing levels or the number of mechanical lifts needed in its facility-wide assessment, resulting in insufficient resources to meet resident care needs. Staff scheduled shifts based on PPD without considering resident acuity or unit-specific needs, and only one full-body lift and one sit-to-stand lift were available, causing delays in care for dependent residents, including those with morbid obesity.
The facility failed to secure medications, leaving a medication cart and treatment cart unlocked and unattended, and medications were left at a resident's bedside. An LPN admitted to leaving a medication cart unlocked, and a wound care nurse left a treatment cart unattended. A resident was found with medications left on their bedside table, which the LPN confirmed was against procedure. The resident was cognitively intact with a history of cerebral infarction.
The facility failed to respect resident dignity and privacy in two incidents. A CNA attempted to check a resident for incontinence in the hallway against his wishes, despite the resident's request to delay care. The resident, diagnosed with paraplegia, resisted the CNA's actions. In another case, a resident's urinary catheter drainage bag was left uncovered, exposing the urine. Both an LPN and the DON confirmed that such bags should be kept in privacy covers. The resident had a diagnosis of neuromuscular dysfunction of the bladder.
A facility failed to label and date enteral feeding bags for a resident receiving nutrition via a feeding tube. Observations showed that the bags were not labeled with the formula name, date, or time. Interviews with staff revealed a lack of accountability between shifts, with an LPN and the DON indicating it was the night nurses' responsibility to label the bags, which was not done.
A resident with Type 2 Diabetes Mellitus had a change in physician's orders from HumaLog KwikPen with sliding scale coverage to weekly accuchecks. The care plan was not updated to reflect this change, as the care plan nurse responsible was on vacation. The LPN and DON confirmed the oversight, which could lead to confusion in care. Facility policy mandates care plan revisions with order changes, but this was not followed.
A facility failed to conduct a safety smoking assessment for a resident, violating its policy to ensure a safe environment for smokers. The resident, who has been at the facility since 2013 and is cognitively intact, had not been reassessed for smoking safety since 2021. This oversight was confirmed by interviews with the resident, an LPN, and the DON, who acknowledged the lapse in following the facility's policy.
A facility failed to secure the indwelling catheter tubing for a resident with neuromuscular dysfunction of the bladder, as observed during a survey. Despite a physician's order to check and replace the urinary catheter leg strap every shift, the resident did not have a leg strap in place. The facility's policy requires securing catheters to prevent infections, but staff did not adhere to this procedure, as confirmed by the CNA, LPN, and DON.
The facility failed to ensure that residents were treated and spoken to in a dignified and respectful manner. Multiple interviews and record reviews revealed that an LPN routinely spoke to residents in a loud, rude, and aggressive manner, despite having received multiple warnings and additional training. The residents involved had varying degrees of cognitive function, with one being cognitively intact and the other showing no cognitive impairment.
A resident, who was cognitively intact and not identified as an elopement risk, managed to kick open an entrance door and exit the facility unnoticed. The resident was found by the police approximately 12 miles away after being unsupervised for about six to eight hours. The facility's failure to secure the entrance door and provide adequate supervision led to the incident.
The facility failed to treat residents with dignity and respect by not consistently ensuring that call lights were answered in a timely manner. Multiple residents reported waiting for extended periods, sometimes over two hours, for assistance, leaving them wet and soiled. The issue was confirmed by the Ombudsman and acknowledged by the facility's staff, who had conducted multiple in-services to address the problem.
The facility failed to obtain informed consent for the use of bed rails for seven residents. Observations and medical record reviews revealed that bed rails were in use without signed consent forms, which was confirmed by interviews with facility staff, including the Administrator and DON.
Failure to Properly Secure Wheelchair During Van Transport Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to properly secure a resident’s wheelchair in the facility van, resulting in a fall during transport. The facility’s accident/incident policy stated that all persons involved in an incident or accident, or suspected to have had one, are to be evaluated, treated as indicated, and monitored. For one resident who depended on a wheelchair for mobility, the incident report documented that while en route to a medical appointment, the resident fell backwards in the wheelchair and hit the back of the head, causing a small hematoma. The facility’s investigation concluded that although the resident was strapped in, the transportation assistant failed to ensure that the wheelchair straps were appropriately placed to firmly secure the chair, which allowed the chair to roll backwards. The QAPI committee’s review identified the primary cause of the fall as the resident’s wheelchair not being properly secured with appropriate straps to maintain a stable and secure position during transportation. CNA #1 reported that she used four hooks to secure the wheelchair frame to the van’s securement system and that the wheelchair was attached to the floor. During transport, she heard a noise, looked back, and saw the resident on the van floor with the wheelchair turned on its side and the seatbelt no longer secured around the resident. CNA #1 stated that the resident reported hitting her head and having head pain. CNA #2, who was driving, similarly reported hearing a noise, then observing the resident on the floor with the wheelchair on its side, and confirmed that no checklist was used to verify correct securement of the wheelchair. The Administrator stated she was notified shortly after the incident that the resident’s wheelchair had fallen over in the van and that the resident had hit her head and complained of head pain. The Maintenance Supervisor later inspected the van’s resident securement system and found all components intact and functioning correctly, indicating that the issue was not equipment failure but how the securement system was used. The resident’s records showed admission with diagnoses including COPD, heart failure, and rheumatoid arthritis, and a significant change MDS with a BIMS score of 9, indicating moderate cognitive impairment, and a need for a wheelchair for mobility. The hospital After Visit Summary documented that the resident was evaluated in the emergency department for a fall and head injury, with imaging showing no new diagnoses, and treatment with an over-the-counter analgesic.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment and a history of depression, repeated falls, and chronic atrial fibrillation was able to exit the facility unsupervised. The resident was last seen by staff at 10:37 AM and subsequently left the building behind a hospice nurse, with no staff intervening to prevent the exit. The resident was observed by a physical therapist assistant (PTA) leaving the facility, but the PTA assumed the resident was accompanied by staff and did not verify this or intervene. The resident continued out of the facility and was not stopped or redirected by any staff members, despite facility policies requiring supervision and intervention for residents at risk of elopement. The resident was outside and unsupervised for approximately 22 minutes, during which time she traveled 0.4 miles away from the facility, down a busy four-lane street, and was eventually found in the parking lot of a local funeral home. The resident was dressed in a sweatshirt and jeans, and the temperature was 51 degrees Fahrenheit. Interviews with staff revealed that there was a lack of immediate response to the resident's absence, and the missing resident procedure was not initiated promptly. Staff failed to maintain awareness of the resident's movements near the exit, and the facility's wandering and missing resident procedures were not followed as required. The facility's policy required that residents at risk for elopement be identified, have preventative plans of care implemented, and receive visual supervision as necessary. In this incident, the resident was not identified as being at risk for elopement at the time, and staff did not provide the required supervision or intervention. The failure to follow established procedures and to provide adequate supervision resulted in the resident being placed in a situation likely to cause serious injury, harm, impairment, or death.
Removal Plan
- Initiated a search within the building and outside the parameters for Resident #9 upon notification of elopement.
- Administrator checked Resident #9's room and the front entrance.
- Social Service Director (SSD) and Physical Therapy Assistant (PTA) assisted in searching outside.
- Located Resident #9 in front of the funeral home, 0.4 miles from the facility.
- Ensured Resident #9 was safe and uninjured.
- SSD called Resident #9's Resident Representative (RR) and informed her of the incident.
- Printed census for North and South unit and completed a head count to ensure all residents were accounted for.
- Completed a body audit on Resident #9 by RN with no injuries noted.
- Reported the incident to the State Agency.
- Maintenance completed an audit on all doors and windows to ensure proper functioning.
- On-call Nurse Practitioner (NP) notified and new order for in-house psych evaluation given.
- Medical Director, Medical Doctor (MD), and NP #2 notified by Administrator of the incident.
- All staff in-services began on Elopement/Unsafe wandering plan and the Emergency Procedure - Missing Resident and Abuse and Neglect; completed by Assistant Director of Nursing (ADON).
- Conducted an Elopement Drill by Maintenance Director, completed on all shifts and to be continued weekly for four weeks and monthly for three months.
- Held an emergency Quality Assurance Performance Improvement (QAPI) meeting with IDT members to discuss the incident, actions to be taken, and further interventions.
- Reviewed policy with QAPI committee; no recommendations for change.
- Added Resident #9 to the wander book and provided a wander guard.
- Person-centered in-services to be completed with staff whenever any new residents are identified as an elopement risk.
- Elopement drill on all shifts and one elopement drill per week on alternating shifts for four weeks, then monthly for three months.
- Head count by census.
- Maintenance quality check on all doors and windows.
- SSD to complete 100% audits on all wanderers, update wander book, update care plans, in-service on wander book location, conduct interview with resident for any psychosocial harm.
- Updated Medication Administration Record (MAR) with hourly visual monitoring for Nursing by RN.
- Point of Care (POC) updated for hourly visual tasks for CNAs to mark complete by MDS Nurse.
- SSD conducted interview with resident to assess psychosocial harm.
- Placed Wander Guard bracelet on Resident #9's left wrist.
- Care plans updated by SSD.
- 100% audit done on all wanderers by SSD and Wander Book updated with photos and face sheets.
- 100% audit done by SSD on all Wander Guard bracelets to ensure appropriate functional ability.
- Maintenance Director to perform elopement drills on all shifts, continue for four weeks and monthly for three months, and bring results before the QAPI committee each month for review and recommendations.
- Any issues to be addressed immediately by the Administrator and the DON.
- Incident reported to the Attorney General's Office by Administrator.
Failure to Prevent Repeated Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from repeated physical abuse by another resident, resulting in injury. Multiple incidents of resident-to-resident aggression occurred between two residents, both of whom were cognitively intact according to their Brief Interview for Mental Status (BIMS) scores. Despite ongoing abusive interactions, including physical altercations such as hitting, slapping, and use of objects to inflict harm, the facility did not implement effective interventions to prevent further abuse. Staff were aware of the ongoing relationship and history of aggression between the two residents, but hourly monitoring and room changes did not prevent the incidents, as the residents continued to seek each other out. Documentation and interviews revealed that staff, including CNAs, LPNs, and the Social Services Director, were aware of multiple incidents over several months. These included physical assaults resulting in visible injuries such as periorbital edema and redness to the eye, which required pain medication. The facility's policy required the prevention of abuse and the provision of a safe environment, but staff did not escalate supervision or consider one-on-one monitoring, even after repeated events. There was also a lack of consistent documentation for all incidents, and some staff could not recall if incident reports were completed. The residents involved had significant medical histories, including hemiplegia, diabetes, chronic kidney disease, and heart failure. Both residents had been referred to psychiatric and psychosocial services, and discharge planning was underway for one resident. However, these actions did not prevent further abuse prior to the most recent incident. The facility's failure to implement effective measures to separate or supervise the residents resulted in continued physical harm and did not uphold the residents' right to be free from abuse.
Failure to Maintain Resident Dignity by Not Concealing Catheter Bag
Penalty
Summary
The facility failed to uphold a resident's right to respectful and dignified care by not properly applying a privacy cover to an indwelling urinary catheter collection bag. According to the facility's urinary catheter care policy, a privacy bag should be placed over the drainage bag when the resident is in public areas to preserve dignity. However, during an observation, the catheter bag was attached to the bed frame and was visible from the open doorway, displaying its contents. The blue snap-on catheter bag cover was present but left unsnapped, failing to conceal the bag or its contents. The resident involved had been admitted with diagnoses including hemiplegia, hemiparesis following cerebral infarction, and neuromuscular dysfunction of the bladder. The resident was documented as having severe cognitive impairment and was unable to participate in mental status interviews. The deficiency was confirmed during an interview with the DON, who acknowledged that the catheter cover had not been properly applied and did not provide adequate privacy for the resident.
Failure to Provide Disposable Premoistened Cleansing Cloths for Residents with Wounds
Penalty
Summary
The facility failed to provide reasonable accommodation of resident needs and preferences by discontinuing the use of disposable premoistened cleansing cloths for four residents who had wounds or fragile skin. Despite informing residents and staff that these cloths could be provided for incontinent residents with wounds due to their softer texture, the facility did not make them available. Observations confirmed the absence of these wipes in the supply room, and multiple residents and staff reported that the facility had stopped supplying them, replacing them with dry disposable wipes or washable cloths that were described as rough, thin, and inadequate for care. Residents with wounds and fragile skin expressed dissatisfaction with the alternative products, stating that the dry wipes were not soft, tore easily, and left lint, while the washable cloths were rough and irritating. Some residents and their families resorted to purchasing the premoistened wipes themselves to meet care needs. The Resident Council President and the facility Ombudsman both confirmed that the discontinuation of the wipes had been a topic of concern among residents, with reports of postponed or interrupted care due to inadequate supplies. Medical record reviews for the affected residents showed that they had significant medical conditions, including wounds requiring daily care, diabetes, end-stage renal disease, and impaired mobility. Orders for wound care and skin treatments were documented, and residents were assessed as dependent on staff for hygiene and toileting. Despite these needs and the facility's policy to accommodate resident preferences unless it endangered health or safety, the facility did not provide the premoistened cleansing cloths as previously indicated.
Failure to Maintain Safe Wheelchair Equipment and Provide Adequate Linens
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment for residents, specifically those dependent on wheelchairs and those requiring adequate linens for personal care. Two residents who relied on wheelchairs experienced issues with the condition and maintenance of their mobility devices. One resident's wheelchair had both armrests torn and missing all cushioning, causing discomfort, while another resident's personalized mechanical wheelchair had a broken armrest that had not been repaired for approximately two weeks after being damaged during a transfer. Staff, including nurses and therapists, were aware of these issues, but repairs were delayed or not initiated due to uncertainty about insurance coverage and lack of communication among staff and management. Additionally, the facility failed to provide adequate clean linens for resident care. On a specific day, staff reported a lack of clean towels and facecloths, resulting in postponed or interrupted personal hygiene care, such as bed baths and incontinence care. Staff described having to divide limited clean linens among residents and confirmed that some residents did not receive timely or sufficient care due to the shortage. The facility had discontinued the use of disposable premoistened cleansing cloths, relying instead on washable cloths and dry disposable wipes, which staff and residents described as inadequate for effective care, especially for those with fragile skin or wounds. Multiple staff interviews confirmed that the lack of clean linens and limited availability of mechanical lifts led to delays in resident care, including bathing, transfers, and incontinence care. Residents and their families reported dissatisfaction with the quality and timeliness of care, citing postponed assistance and the need to supply their own cleansing cloths. The facility's housekeeping supervisor attributed the linen shortage to miscommunication regarding staff scheduling, and there was confusion among staff about the location of clean linen storage, further contributing to the deficiency.
Failure to Timely Report Resident-on-Resident Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of resident-on-resident physical abuse to the State Agency within the required timeframe, as mandated by federal regulations. On the evening of 6/09/25, a certified nursing assistant (CNA) witnessed one resident strike another near the vending machines and immediately reported the incident to a registered nurse (RN) and a licensed practical nurse (LPN). The incident was also communicated to the Social Services Director (SSD) and the facility Administrator by the following day. Despite internal investigation and staff awareness, the allegation was not reported to the State Agency as required by facility policy and federal law. Interviews with staff confirmed that the incident was observed, reported, and discussed among multiple staff members, including the SSD, DON, and Administrator. The Administrator acknowledged awareness of the incident but chose not to report it to the State Agency, citing ongoing incidents between the two residents and a denial from the alleged victim during an interview. Documentation in the progress notes for the alleged perpetrator did not reflect the incident until nearly two weeks later, and the facility's investigation records confirmed that an internal review was conducted starting on the date of the incident. Both residents involved had a history of ongoing altercations and were known to seek each other out despite interventions such as room changes. The resident alleged to have committed the abuse had diagnoses of hemiplegia and diabetes, with no cognitive impairment per the most recent MDS. The alleged victim had chronic kidney disease, heart failure, and fluctuating cognitive status, with recent MDS scores indicating moderate to no cognitive impairment. The facility did not implement one-on-one supervision or other measures to ensure resident safety at the time of the incident.
Failure to Provide Adequate Nail Care During ADL
Penalty
Summary
The facility failed to provide adequate personal hygiene, specifically fingernail and toenail care, for two residents during Activities of Daily Living (ADL) care. Observations revealed that both residents had long fingernails, with a black substance under each nail, extending significantly past the ends of their fingers. One resident also had toenails that were excessively long. Both residents expressed a desire to have their nails trimmed. The facility's policy included nail care as part of ADL care, and supplies for nail care were available in the unit. Record reviews showed that one resident had severe cognitive impairment with diagnoses of Chronic Obstructive Pulmonary Disease and Alzheimer's Disease, while the other had no cognitive impairment and diagnoses including paraplegia and muscle weakness. Interviews with nursing staff and the DON confirmed that nail care was the responsibility of licensed nursing staff and was included in routine care, with a system in place for podiatrist visits for toenail care. Despite these policies and available resources, the necessary nail care was not provided to the two residents.
Failure to Assess and Document Resident After Fall
Penalty
Summary
The facility failed to evaluate and analyze hazards and risks, and did not assess a resident following a documented fall. According to the facility's fall policy, when a fall occurs, an incident and accident report should be completed, documentation should be initiated and continued for at least three days, a fall investigation and supervisor report should be completed, and the care plan should be updated. For one resident with a history of falls and diagnoses including Paranoid Schizophrenia, muscle weakness, and altered mental status, a fall was documented in the progress notes. However, there was no evidence of an incident report, follow-up monitoring, or required documentation related to this fall. Interviews with staff revealed confusion and lack of recall regarding the incident, with the LPN and staffing coordinator both unable to remember the fall or confirm that it was reported. The DON confirmed that protocol required assessment and documentation after a fall, but was unable to provide any documentation for the incident in question. The administrator also could not locate any incident report or related documentation, despite the fall being noted in the resident's progress notes. The resident was described as cognitively intact at the time of the incident.
Unsecured Medication Storage in Resident Room
Penalty
Summary
Facility staff failed to safely and securely store medications for one resident. During an observation, two vials of Ipratropium-Albuterol Inhalation Solution were found on the overbed table in the resident's room, with one vial opened and one unopened. The resident reported that nurses had left the medications for her and was unsure if there were more vials elsewhere. There was no individual medication storage cabinet in the room, and the Director of Nursing was unaware that medications were being stored unsecured in the resident's room. A review of facility policy indicated that medications and biologicals are to be stored safely, securely, and properly, accessible only to authorized personnel, and that bedside storage is only permitted with a prescriber's written order for residents able to self-administer. The resident had a BIMS score indicating no cognitive impairment and had an active physician order for the inhalation solution, but there was no physician order permitting storage of medications in the resident's room. Both the DON and Administrator confirmed that all medications were expected to be stored in locked medication rooms or carts.
Failure to Assess and Provide Adequate Staffing and Equipment
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine the resources necessary to competently care for residents during both routine operations and emergencies. The facility's assessment did not include information regarding the number of staff required or the number of mechanical lifts needed to meet the needs of the resident population. Policy review indicated that the facility was required to assess equipment, supplies, and personnel annually, but the actual assessment lacked these critical details. The staffing policy also referenced the facility assessment as a basis for determining sufficient staffing, but this was not reflected in practice. Interviews with the Staff Development Coordinator (SDC) revealed that staffing was scheduled based on per patient day (PPD) calculations without consideration of resident acuity or specific care needs on different units. The SDC was unaware of the facility assessment's role in staffing decisions. Observations and interviews with the DON and Administrator confirmed that only one full-body lift and one sit-to-stand lift were available, and that if a lift was in use on one unit, residents on the other unit experienced delays in care. The Administrator acknowledged that the facility assessment did not address the number of lifts or staffing levels needed to provide timely care, affecting all residents, including those with higher dependency and diagnoses such as morbid obesity.
Medication Security and Administration Deficiencies
Penalty
Summary
The facility failed to ensure the security of medications and biologicals, as evidenced by an unlocked and unattended medication cart and treatment cart, as well as medications left at a resident's bedside. During an observation on the North Unit, a medication cart was left unlocked and unattended for several minutes, with ten residents walking past it. The LPN responsible for the cart admitted it was an accident and acknowledged the potential risks of residents accessing the medications, which included liquid valproic acid and over-the-counter medications. Similarly, a treatment cart was left unlocked while a wound care nurse was attending to a resident, containing items such as scissors and antimicrobial solutions that should not be accessible to residents. Additionally, medications were left unattended at a resident's bedside. A resident was observed with a medication dispensing cup containing multiple tablets and capsules on their bedside table. The LPN confirmed that she left the medications unattended, which was against the facility's procedure, as it prevented her from knowing if the resident had taken the medication. The DON confirmed that leaving medications at the bedside was improper procedure. The resident involved was cognitively intact, with a BIMS score of 15, and had a medical history including a cerebral infarction.
Failure to Respect Resident Dignity and Privacy
Penalty
Summary
The facility failed to uphold residents' rights to dignity and respect in two separate incidents. In the first incident, a Certified Nurse Aide (CNA) attempted to check a resident for incontinence in the hallway against his wishes. The resident, who was listening to a church service, expressed his desire to delay care until later in the day. Despite this, the CNA proceeded to push the resident's wheelchair and attempted to look inside his pants, prompting the resident to resist and verbally express his desire to be left alone. The CNA acknowledged her actions were inappropriate, attributing them to her attempt to complete her duties before the end of her shift. The resident involved had a diagnosis of paraplegia and was cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 15. In the second incident, another resident was observed with a urinary catheter drainage bag visibly hanging from his wheelchair without a privacy cover, leaving the urine exposed. The resident, who was unsure of the duration or reason for having the catheter, noted that the bag is usually covered when he is outside his room. Both a Licensed Practical Nurse (LPN) and the Director of Nursing (DON) confirmed that catheter drainage bags should be kept in privacy bags to prevent the urine from being visible to others. This resident also had a BIMS score of 15, indicating cognitive intactness, and had a diagnosis of neuromuscular dysfunction of the bladder with an order for a suprapubic catheter.
Removal Plan
- CNA will no longer be assigned to the resident
- District Ombudsman was contacted
Failure to Label and Date Enteral Feeding Bags
Penalty
Summary
The facility failed to properly label and date enteral feeding bags for a resident receiving nutrition via a feeding tube. During multiple observations, it was noted that the feeding tube bags for Resident #24 were not labeled with the name of the formula, the date, or the time when the bags were hung. This was observed on three separate occasions, indicating a consistent failure to adhere to the facility's policy regarding enteral feeding procedures. Interviews with staff revealed a lack of accountability and communication between shifts. An LPN confirmed that the feeding bags were not labeled and explained that it was the responsibility of the previous shift to change and label the bags. The Director of Nursing also stated that it was the night nurses' responsibility to ensure the bags were labeled correctly. Despite these established responsibilities, the feeding bags remained unlabeled, demonstrating a breakdown in the facility's protocol for managing enteral feedings.
Failure to Revise Care Plan Following Change in Physician's Order
Penalty
Summary
The facility failed to revise a comprehensive care plan intervention when a physician's order changed for a resident diagnosed with Type 2 Diabetes Mellitus. The resident had a previous physician's order for HumaLog KwikPen with sliding scale coverage, which was discontinued. A new order was issued for weekly accuchecks, but the care plan was not updated to reflect this change. This oversight was identified through staff interviews, record reviews, and facility policy reviews. The care plan nurse, responsible for updating care plans based on new orders, was on vacation at the time of the deficiency. The LPN and the Director of Nursing confirmed that the care plan had not been revised, which could lead to confusion in resident care. The facility's policy requires care plans to be revised as residents' conditions and orders change, but this was not adhered to in this instance.
Failure to Conduct Smoking Safety Assessment
Penalty
Summary
The facility failed to conduct a safety smoking assessment for a resident, which is a violation of their policy to provide a safe environment for residents who smoke. The policy requires that residents with a known history of smoking be evaluated on admission, quarterly, and as needed for safety awareness and any physical limitations related to smoking safety. However, Resident #1, who has been a resident since 2013 and has a history of smoking, did not have a current smoking safety evaluation completed since 2021. This oversight was confirmed during interviews with the resident, an LPN, and the Director of Nurses (DON). Resident #1, who is cognitively intact with a Brief Interview for Mental Status score of 15, has been using tobacco as indicated in her Comprehensive Annual Minimum Data Set (MDS) assessment. Despite her long-term residency and continued smoking habit, the facility failed to reassess her smoking safety, which could potentially put her at risk for burns. The LPN and DON acknowledged the lapse in conducting the necessary assessments, attributing it to an oversight in the nursing supervisors' responsibilities to complete the assessment form as per the facility's policy.
Failure to Secure Indwelling Catheter Tubing
Penalty
Summary
The facility failed to ensure proper care for a resident with an indwelling catheter, as observed during a survey. The resident, who was admitted with a diagnosis of neuromuscular dysfunction of the bladder, had a physician's order to check the urinary catheter leg strap every shift and replace it as needed. However, during an observation of catheter care, it was noted that the resident did not have a leg strap in place to secure the catheter tubing. Both the CNA and LPN confirmed the absence of the leg strap, which is essential to prevent the catheter tubing from pulling or becoming dislodged. The facility's policy on catheter care, dated 8/25/14, clearly states the importance of securing the catheter to prevent catheter-associated urinary tract infections. Despite this policy, the staff failed to adhere to the procedure, as evidenced by the lack of a leg strap for the resident's catheter. The Director of Nursing confirmed that all residents with an indwelling catheter should have a leg strap, and the Administrator expressed an expectation for staff to provide quality care. This deficiency highlights a lapse in following established protocols for catheter care within the facility.
Failure to Ensure Respectful and Dignified Treatment of Residents
Penalty
Summary
The facility failed to ensure that residents were treated and spoken to in a dignified and respectful manner. This deficiency was observed in the cases of two residents. The facility's policy on employee behavior mandates courteous treatment of all residents, visitors, and coworkers, and prohibits offensive behavior. However, multiple interviews and record reviews revealed that an LPN routinely spoke to residents in a loud, rude, and aggressive manner. The facility Ombudsman confirmed receiving complaints about the LPN's behavior, and several residents and a family member provided specific examples of the LPN yelling at residents and giving orders in a disrespectful tone. One resident reported that the LPN was rude and disrespectful, often yelling at residents to go to bed or return to their rooms. Another resident and her family member corroborated these observations, noting that the LPN's loud and aggressive behavior was more than just an attempt to be heard. The family member added that some residents seemed unable to understand the LPN's commands. The previous Resident Council President also mentioned that the LPN's behavior had been discussed in council meetings, although it was unclear if these concerns were formally recorded. The Social Services Director confirmed receiving a grievance about the LPN's behavior, and the Assistant Director of Nursing noted that the LPN had already received multiple coaching and verbal warnings regarding therapeutic communication. Despite routine in-service training on resident rights and respectful treatment, the LPN's behavior persisted. Record reviews showed that the LPN had received a verbal warning and additional training on conduct and therapeutic communication just a month prior to the reported incidents. The residents involved had varying degrees of cognitive function, with one being cognitively intact and the other showing no cognitive impairment.
Resident Elopement Due to Inadequate Supervision and Unsecured Door
Penalty
Summary
The facility failed to provide adequate supervision to prevent a vulnerable resident from exiting the facility unnoticed and unsupervised. The resident was last observed in his room at 1:15 AM, but staff were unaware of his absence until 3:15 AM. After a search of the building and perimeter, it was determined that the resident had left the facility. The resident was found by the police approximately 12 miles away, having been off the facility grounds and unsupervised for about six to eight hours. The resident, who was cognitively intact and not identified as a wanderer or elopement risk, managed to kick open an entrance door to exit the facility. The facility's failure to ensure the entrance door was secure and to provide adequate supervision put the resident and other vulnerable residents at risk for serious harm. The incident was determined to be an Immediate Jeopardy and Substandard Quality of Care. Interviews and record reviews revealed that the facility staff were unaware of the resident's absence until a staff member entered his room at 3:15 AM. The resident was eventually located by the police, wearing appropriate clothing and carrying some belongings. The facility's policies and procedures for missing residents were initiated, but the initial failure to secure the entrance door and provide adequate supervision led to the resident's elopement.
Removal Plan
- The Certified Nursing Assistant (CNA) observed the residents' room and noted he was not present. She immediately notified the Licensed Practical Nurse (LPN) on duty. All staff on the unit began a search for the resident throughout the north unit and then moved to the south unit; at this time, all staff were directed by the LPN to conduct a search of all areas of the building and the perimeter.
- The LPN notified the Administrator in Training (AIT) that the staff searched the building and perimeter and could not locate the resident. The AIT notified the Administrator and Director of Nursing (DON) immediately after speaking with the nurse. The Administrator gave instructions to contact the Maintenance Supervisor and the Police Department. The LPN attempted to contact the resident's next of kin and the number was disconnected.
- The Maintenance Supervisor arrived at the facility. He checked all exit doors for proper functioning and noted all doors were secure. He began a search of the perimeter including outside buildings and checked all windows noting all windows were secure.
- A complete headcount was conducted by the nursing staff and all other residents were located.
- A search team was assembled by the DON and Maintenance Supervisor to search surrounding buildings, including churches, convenience stores, local bus stations and all open businesses. The LPN began making calls to all surrounding police stations. The Administrator contacted all local hospitals.
- The Officer assigned to the case arrived at the facility and completed a missing person's report.
- The Administrator notified the resident's physician to update the missing resident's status.
- The Police Department confirmed with the Administrator that the resident was safe and secure at the Police Station.
- The Director of Nursing and Social Service Director went to the Police Station, assessed the resident, found no issues or psychosocial harm then transferred the resident to the emergency room because he refused transport by ambulance. The resident was calm and expressed confidence in his purpose for leaving the facility. He stated he kicked the door, left the facility, walked to the corner of the road, caught a ride with two white ladies that helped him make a sign so he could get to (name of city) to see his family.
- The DON arrived at the hospital, gave history of incident and medical information to the Physician along with current medications and morning medications that he had not received at this time. The DON remained with the resident while the nurse obtained vital signs including a blood glucose level and body audit. No issues were noted with skin assessments, all vital signs were within normal limits and the resident stated he felt fine, but his legs were sore. The Physician ordered labs and stated they would complete medical clearance for admittance.
- A Quality Assurance Performance Improvement (QAPI) committee meeting was held regarding the incident involving Resident # 1. In attendance were the Administrator, the DON, the AIT, the Care Plan Nurse, the Assistant Director of Nursing (ADON)/Infection Preventionist (IP), the Business Office Manager, the Maintenance Supervisor, the Wound Care Nurse, Medical Director, the Regional Nurse Consultant, the Regional Director of Operations, and the Social Services Director (SSD).
- The QAPI committee reviewed the incident, actions taken, and the policy was reviewed with no recommendations for change.
- All facility staff were 100% in-serviced regarding elopement/missing resident policies and procedures prior to returning to work by the AIT and the DON.
- One hundred percent (100%) of all residents were assessed for elopement risk by the Wound Care Nurse and DON.
- Care Plan Nurse performed a 100% audit of all resident's care plans for those identified as an elopement risk.
- DON completed a 100% audit of all residents that were identified as an elopement risk to include visual monitoring, wander guard bracelets and testing.
- 100% audit of the elopement book was performed by the Social Services Director and to ensure that all pictures were current.
- Maintenance Supervisor performed elopement drills on all shifts, this will continue for four (4) weeks and monthly thereafter and brought before the QAPI committee each month for review and recommendations. Any issues will be addressed immediately by the Administrator and DON.
- Maintenance Supervisor changed all door codes in the facility.
- AIT ordered keypad covers for all door keypads in the building.
- Maintenance Supervisor placed door alarms on all doors in the facility. The alarms will be monitored daily, and any issues will be addressed immediately by the Administrator and brought before the QAPI committee monthly for review and recommendations.
- Maintenance Supervisor contacted the alarm company to schedule testing of all doors in the building.
- State Department of Health (SA) was notified of the incident.
- The Attorney General's office (AGO) was notified of the incident.
Failure to Answer Call Lights Timely
Penalty
Summary
The facility failed to treat residents with dignity and respect by not consistently ensuring that call lights were answered in a timely manner. This deficiency was observed in three sampled residents and one unsampled resident. Resident #32 reported that it took staff over two hours to respond to call lights, leaving him wet and sometimes soiled. Resident #1 stated that she had to lay in urine and bowel movement for over an hour and had complained to the Ombudsman. Resident #45 also complained about the staff not answering call lights timely. Additionally, a grievance was filed by the wife of an unsampled resident regarding the same issue. The Ombudsman confirmed receiving recent complaints about the untimely response to call lights and had discussed the issue with the facility's Assistant Administrator, Social Service Director, and Activity Director. The Director of Nurses acknowledged being aware of the complaints and stated that staff had been in-serviced on the importance of answering call lights promptly. The Activity Director and Social Service Director also confirmed receiving complaints and stated that the Director of Nursing had conducted in-services with the staff. The Administrator confirmed that residents had complained during resident council meetings and that multiple in-services had been conducted to address the issue, with the last one occurring in December 2023.
Failure to Obtain Informed Consent for Bed Rails
Penalty
Summary
The facility failed to obtain informed consent for the use of bed rails for seven out of eighteen residents reviewed. The facility's policy requires that residents or their representatives be informed about the benefits and potential hazards associated with bed rails and that informed consent be obtained before their use. However, observations and medical record reviews revealed that residents #1, #14, #24, #31, #45, #81, and #142 had bed rails in use without signed informed consent forms in their medical records. This was confirmed through multiple observations and interviews with facility staff, including the Maintenance Director, Administrator, and Director of Nursing (DON), who acknowledged the absence of signed consent forms for bed rails in the residents' charts. During the survey, it was observed that the facility had bed rails installed and in use for the mentioned residents without following the required protocol of obtaining informed consent. The Administrator and DON confirmed that the facility did not have a bed rail consent process in place at the time of the survey. This lack of compliance with the facility's policy and regulatory requirements led to the deficiency being cited by the surveyors.
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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