The Oaks Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Meridian, Mississippi.
- Location
- 3716 Highway 39 North, Meridian, Mississippi 39301
- CMS Provider Number
- 255261
- Inspections on file
- 22
- Latest survey
- November 19, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at The Oaks Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident was found with long, jagged toenails and reported not receiving assistance with nail care, despite requesting help. This repeated deficiency occurred due to staff overlooking grooming during ADL care and a lack of effective follow-through on the facility's QAPI plan, as confirmed by interviews with the Administrator and DON.
A resident with severe cognitive impairment and physical limitations did not receive needed assistance with grooming and personal hygiene, including facial hair removal and toenail trimming. Despite expressing a desire for help and being unable to perform these tasks independently, staff did not provide the required care, contrary to facility policy and staff responsibilities.
A blind, cognitively intact resident was unable to access or verify the function of the call light system, as it was consistently placed out of reach and not adapted for her vision impairment. Staff interviews and observations confirmed the call light was attached to the wall at the foot of the bed, leaving the resident to yell for assistance. The DON acknowledged the need for more accessible devices for residents with vision loss.
A resident with severely impaired cognition and a stage 3 pressure ulcer did not receive required weekly skin integrity assessments, as documentation was only completed once despite facility policy and a QAPI intervention. The DON and NHA confirmed that the facility failed to consistently perform and document these evaluations for a high-risk individual.
A CNA failed to provide complete perineal care to a resident with severe contractures and cognitive impairment, cleaning only the anal area and omitting care to the vaginal area after a bowel movement. The omission was confirmed by interviews with the CNA, RN, and DON, and was not in accordance with facility policy or professional standards.
Surveyors found a box of moldy oranges with gnats and an unsealed bag of food thickener exposed to air during a kitchen tour. Dietary staff and management confirmed that these items were not properly stored or disposed of, in violation of facility policy, and acknowledged the potential for foodborne illness due to these lapses.
Staff failed to follow hand hygiene protocols during wound and perineal care for a resident with multiple diagnoses and severe cognitive impairment. A nurse did not perform hand hygiene at each step of wound care, and a CNA did not sanitize hands before donning gloves for perineal care. Facility leadership confirmed these actions did not comply with infection prevention policies and placed the resident at risk for infection.
Two residents with cognitive impairments were subjected to physical and verbal abuse by a CNA, with incidents witnessed by other staff who failed to report the abuse immediately due to fear of retaliation. The delay in reporting resulted in the CNA continuing to work with vulnerable residents for several days, contrary to facility policy and placing residents at risk.
Two residents, both with cognitive impairments, experienced physical and verbal abuse by a CNA, which was witnessed by other CNAs who failed to intervene or report the incidents immediately due to fear of retaliation, despite being trained on the facility's abuse policy and reporting requirements.
Staff failed to promptly report and investigate multiple incidents of physical and verbal abuse involving two residents, with delays attributed to fear of retaliation and oversight. Required notifications to the Administrator and State Agency were not made within mandated timeframes, resulting in Immediate Jeopardy and Substandard Quality of Care.
A resident with Parkinson's Disease and dementia, who exhibited aggressive behaviors, did not receive care in accordance with their individualized care plan. During an episode of agitation, staff failed to follow prescribed interventions such as stepping away and returning later, resulting in inappropriate physical handling and a nosebleed. Facility staff and leadership confirmed the care plan was not followed.
Due to a staffing shortage, only one CNA was present during an overnight shift, leaving a resident with an overactive bladder and urinary incontinence without timely care and resulting in the resident remaining soiled all night. Attempts by LPNs to contact the DON and scheduler for assistance were unsuccessful, and no additional staff could be secured.
The facility's assessment failed to specify staffing needs by shift, lacked a recruitment and retention plan, and did not include contingency planning for non-emergency situations. As a result, a resident with an overactive bladder was left in urine overnight when only one CNA was on duty, highlighting insufficient staff coverage and planning.
Daily nurse staffing information was not posted in a visible and accessible location for two consecutive days. Multiple staff, including LPNs and the DON, confirmed the absence of required postings, and no alternative location was identified. This failure limited access to staffing information for residents, families, and the public.
Repeated Deficiency in Resident Nail Care Due to Ineffective QAPI Implementation
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) plan, as evidenced by a repeated deficiency related to resident grooming. Specifically, the facility was cited for not ensuring that a resident's nails were clipped, an issue that was previously identified in a prior annual recertification survey. During the most recent survey, a resident was observed with long and jagged toenails and expressed that she had not received assistance with nail care, despite requesting help. This observation was supported by staff and resident interviews, as well as a review of facility policies and prior statements of deficiencies. Interviews with facility leadership revealed a lack of clarity regarding the reasons for non-adherence to the previous plan of correction for Activities of Daily Living (ADL) care. The Administrator was unable to specify why the plan was not being followed, while the DON suggested that staff may be overlooking nail care during routine grooming. The facility's policy on QAPI, which outlines the establishment of performance indicators and systematic actions to improve performance, was reviewed but not effectively implemented to prevent recurrence of the deficiency.
Failure to Provide Necessary ADL Assistance for Grooming and Hygiene
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and physical limitations did not receive necessary assistance with activities of daily living (ADLs), specifically grooming and personal hygiene. Observations revealed the resident had long, visible facial hair on her chin and upper lip, as well as long, jagged toenails. The resident expressed a desire for assistance with hair removal and toenail trimming, stating that staff had not provided this help and that she was unable to perform these tasks herself due to her health challenges. Interviews with staff confirmed that grooming tasks, including facial hair removal, are the responsibility of CNAs during daily ADL care, and toenail trimming is assigned to LPNs. Staff members were not aware of the resident refusing care, and both the DON and LPN confirmed that these services should have been provided. The facility's policy requires staff to encourage resident participation in ADLs and provide assistance as necessary, but this was not followed for the resident in question.
Failure to Individualize Call Light System for Blind Resident
Penalty
Summary
The facility failed to reasonably accommodate the needs of a blind resident by not individualizing the call light system to ensure accessibility. The resident, who is legally blind and cognitively intact, reported being unable to see or reach the call light in her private room. She stated that even when the call light was within reach, she could not determine if it was functioning, leading her to feel uncertain and vulnerable when needing assistance. Multiple interviews with staff, including a CNA and an LPN, confirmed that the call light was attached to the wall at the foot of the bed and was not accessible to the resident. Staff acknowledged that the call light was not placed within the resident's reach during the night and that this was a consistent issue. Observations conducted by surveyors corroborated the resident's statements, as the call light was repeatedly found out of reach. The Director of Nursing also recognized the need for a more accessible device for residents with vision impairments. The facility's policy on resident rights was reviewed, which mandates that residents are not deprived of their rights, but the policy was not followed in this case. The resident's medical record confirmed her legal blindness and anxiety disorder, further emphasizing the necessity for individualized accommodations that were not provided.
Failure to Document Weekly Skin Integrity Assessments for High-Risk Resident
Penalty
Summary
The facility failed to ensure ongoing assessment and documentation of skin integrity for a resident at high risk for skin breakdown. According to facility policy, a licensed nurse is required to complete and document a total body skin evaluation weekly for each resident. However, for one resident with a history of contractures and a stage 3 pressure ulcer, the Weekly Skin Integrity Review was only documented once, with no further weekly assessments recorded as required. This lapse occurred even after a QAPI intervention was initiated, and the lack of documentation persisted. Interviews with the DON confirmed that the facility was aware of the missed reviews but did not effectively implement the QAPI plan, resulting in continued failure to document weekly skin checks for the high-risk resident. The NHA also acknowledged that the facility did not follow through with its internal corrective strategies. The resident in question had severely impaired cognition and required ongoing wound care for a stage 3 pressure ulcer, as indicated by physician orders and clinical records.
Incomplete Perineal Care Provided to Resident with Contractures
Penalty
Summary
A deficiency was identified when a Certified Nursing Assistant (CNA) failed to provide complete perineal care to a resident with a history of muscle contractures and severely impaired cognition. During an observed wound care session, the CNA cleaned only the anal area after a bowel movement, neglecting to clean the front vaginal area as required by facility policy and professional standards. The CNA did not perform hand hygiene upon re-entering the room before donning gloves and did not follow the protocol of cleaning from front to back to avoid contamination. Interviews with the CNA, the Registered Nurse (RN) assisting with wound care, and the Director of Nursing (DON) confirmed that the perineal care was incomplete and not performed according to policy. The staff acknowledged that the resident, who was contracted and difficult to clean, did not receive care to the vaginal area, which was required. The facility's policy and staff statements indicated that the omission placed the resident at risk for complications.
Improper Food Storage and Disposal in Dietary Services
Penalty
Summary
During a kitchen tour, surveyors observed a ten-pound box of Sunkist oranges under a prep table that was three-fourths full and contained three oranges with black and white mold. Gnats were seen flying out of the box when it was opened. Additionally, an unsealed bag of food thickener with a hole in it was found exposed to the air. Both items were not properly stored or disposed of according to the facility's food preparation policy, which requires staff to avoid contamination by harmful agents. Interviews with dietary staff and management confirmed that the oranges had been received earlier in the month and should have been discarded, and that the thickener should have been sealed and dated. The Dietary Manager acknowledged responsibility for checking behind the cook, and the cook admitted to not paying attention to proper storage procedures. The Director of Food Services and the Nursing Home Administrator both confirmed that these lapses could lead to foodborne illness and that staff are expected to maintain proper food storage and dating compliance.
Failure to Follow Hand Hygiene Protocols During Wound and Perineal Care
Penalty
Summary
The facility failed to provide perineal and wound care in a manner that prevents the spread of infection for two of five observed care events involving a resident with multiple diagnoses, including contracture of muscle and essential hypertension, and severely impaired cognition. During wound care, the registered nurse did not perform hand hygiene after initiating the procedure, and the certified nursing assistant did not sanitize hands before applying clean gloves after returning to the room to assist with perineal care. Both staff members acknowledged their lapses in hand hygiene, with the CNA admitting to forgetting to wash hands and the RN confirming failure to perform hand hygiene at each step of the wound care process, including after cleansing, drying, applying collagen, and dressing the wound. Interviews with the infection preventionist and the director of nursing confirmed that both staff members did not follow facility policies regarding hand hygiene and glove changes during wound and perineal care. The facility's policies require hand hygiene before and after care, as well as glove changes and hand sanitization at each phase of wound care. The staff's failure to adhere to these protocols placed the resident at risk for wound and urinary tract infections, as confirmed by the facility's leadership during interviews.
Failure to Protect Residents from Abuse Due to Delayed Reporting and Inaction
Penalty
Summary
The facility failed to protect residents from physical and verbal abuse, as evidenced by two separate incidents involving a certified nurse aide (CNA). In one incident, a CNA was witnessed physically abusing a resident with Parkinson's Disease and Dementia, who had moderately impaired cognition. The CNA grabbed the resident's nose and twisted it, causing bleeding, and made a derogatory comment. In another incident, the same CNA verbally threatened a different resident, who had severe cognitive impairment and was dependent on staff for toileting hygiene, by stating she would beat the resident if she soiled the bed again. Both incidents were witnessed by other CNAs. Despite these events, the staff members who witnessed the abuse did not immediately report the incidents to the nurse, DON, or Administrator. The witnesses cited fear of retaliation and concerns about job security as reasons for not reporting. As a result, the Administrator was not informed of the allegations until ten days after the initial incident, leaving the residents and others vulnerable during that period. Interviews with additional staff revealed that the CNA in question was known to speak to residents in an aggressive or angry manner, but this behavior was dismissed by some staff as part of her personality and not reported to management. The facility's own policy required immediate reporting and action in cases of abuse, but this was not followed. The delay in reporting and lack of immediate protective action allowed the CNA to continue working with vulnerable residents, placing them at risk for further harm. The deficiency was identified through interviews, record reviews, and the facility's internal investigation, which substantiated the abuse allegations based on staff witness statements.
Removal Plan
- Quality Assurance (QAPI) Committee met to review, develop, and implement the facility policy on abuse and neglect with an emphasis on reporting abuse and neglect and to determine the root cause. The root cause was determined to be that employees were afraid of retaliation from other employees. Attendees included the Executive Director, Minimum Data Service nurse, Medical Records, Regional Director of Clinical Services, Assistant Director of Nursing, Medical Director, Social Services, Staff Development/Infection Preventionist nurse, Activities Director, Human Resources, Housekeeping, Dietary Manager, Therapy director, Unit Managers, and the Admission Coordinator. No changes were made to the policy and procedure. The areas discussed were the re-education of staff members on the abuse and neglect policy with an emphasis on reporting requirements and that failure to do so is a crime.
- Body audits were completed on Resident #1 and Resident #2 by the Staff Development nurse and a licensed nurse. No signs of physical abuse were identified.
- Interviews were conducted by Social Services Director with alert and oriented residents on side 2. No residents voiced complaints of abuse.
- The physician and the Resident Representatives of Resident #1 and Resident #2 were notified.
- Education was started by the Staff Development Nurse.
- Quality Assurance Performance Improvement Committee met to review the physical and verbal abuse.
- Social Services completed a psychosocial follow up with Resident #1 and Resident #2.
- 100% body audits were performed on all facility residents by the unit manager RN and the Minimum Data Set nurses to ensure that residents did not have physical signs of abuse. No residents were identified.
- The Executive Director was educated on the abuse policy by the Regional Director of Clinical Services and timely reporting of abuse within 2 hours to the state agency, attorney general and the abuse and neglect policy.
- The Social Services Director and the Admissions Coordinator interviewed all alert and oriented residents (census) using the Risk Management Quality Improvement Questionnaire to determine if any residents had been abused or witnessed abuse. There were no residents that voiced any complaints of abuse.
- The Staff Development nurse started education with licensed nurses, CNA's and non-direct care staff on the abuse and neglect policy and procedure with an emphasis on reporting requirements and 100% has been completed.
- All facility staff members were interviewed by the Executive Director, Human Resources, and Assistant Director of Nursing by phone to ask if they ever witnessed any employee abuse a resident and explained the process of what to do if they ever witness abuse or neglect, with an emphasis on reporting requirements and that failure to do so is a crime.
- CNA #2 received one on one education on the abuse policy and the reporting requirements with an emphasis placed on the fact of not reporting being a crime.
- New hires will be educated during orientation.
Failure to Implement Abuse Policy and Immediate Reporting
Penalty
Summary
The facility failed to implement its abuse policy, resulting in two incidents of abuse involving two residents. In the first incident, a resident with Parkinson's Disease and Dementia, who had a moderately impaired cognitive status, was physically abused by a CNA during care. The CNA responded to the resident's combative behavior by grabbing and twisting the resident's nose, causing it to bleed, and made a derogatory comment. This act was witnessed by another CNA, who did not immediately report the incident or intervene effectively, despite being aware of the facility's abuse policy and having received training on the obligation to report abuse. In the second incident, another resident with severe cognitive impairment and dependent on staff for toileting hygiene was verbally abused by the same CNA. The CNA threatened the resident with physical harm if the resident soiled the bed again. This was overheard by a different CNA, who confronted the abusive CNA but also failed to report the incident at the time. Both witnessing CNAs later admitted they did not report the abuse immediately due to fear of retaliation from other staff members, even though they were aware of the reporting requirements outlined in the facility's policy. The facility's policy required all employees to report any witnessed or known abuse within two hours to the Administrator and other officials as per state law. However, the incidents were not reported until anonymous letters were received by the Administrator, leading to a delayed response. The failure of staff to intervene and promptly report the abuse placed the affected residents and others at risk for further abuse and constituted a violation of residents' rights to be free from abuse.
Removal Plan
- Quality Assurance (QAPI) Committee reviewed, developed, and implemented the facility policy on abuse and neglect with an emphasis on reporting abuse and neglect and to determine the root cause.
- Body audits were completed on Resident #1 and Resident #2 by the Staff Development nurse and a licensed nurse.
- Interviews were conducted by Social Services Director with alert and oriented residents on side 2.
- The physician and the Resident Representatives of Resident #1 and Resident #2 were notified.
- Education was started by the Staff Development Nurse.
- Quality Assurance Performance Improvement Committee reviewed the physical and verbal abuse.
- Social Services completed a psychosocial follow up with Resident #1 and Resident #2.
- 100% body audits were performed on all facility residents by the unit manager RN and the Minimum Data Set nurses to ensure that residents did not have physical signs of abuse.
- The Executive Director was educated on the abuse policy by the Regional Director of Clinical Services and timely reporting of abuse to the state agency, attorney general and the abuse and neglect policy.
- The Social Services Director and the Admissions Coordinator interviewed all alert and oriented residents using the Risk Management Quality Improvement Questionnaire to determine if any residents had been abused or witnessed abuse.
- The Staff Development nurse started education with licensed nurses, CNAs and non-direct care staff on the abuse and neglect policy and procedure with an emphasis on reporting requirements.
- All facility staff members were interviewed by the Executive Director, Human Resources, and Assistant Director of Nursing by phone to ask if they ever witnessed any employee abuse a resident and explained the process of what to do if they ever witness abuse or neglect, with an emphasis on reporting requirements.
- CNA #2 received one on one education on the abuse policy and the reporting requirements with an emphasis placed on the fact of not reporting being a crime.
- New hires will be educated during orientation.
Failure to Timely Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to report suspected abuse within the required two-hour timeframe and did not submit a completed investigation for an allegation of abuse within five working days, as required by regulation. Two residents experienced abuse by a CNA, with one incident involving physical abuse resulting in a nosebleed and verbal abuse, and another incident involving verbal threats. Both incidents were witnessed by other CNAs, but neither was reported immediately due to fear of retaliation from staff. The abuse was only reported ten days after the initial incident, when anonymous letters were left for the Administrator. The facility's policy required any employee who witnesses or has knowledge of abuse, neglect, exploitation, or mistreatment to report the information within two hours to the Administrator and other officials in accordance with state law. Despite this, the CNAs who witnessed the abuse did not report it promptly, leaving residents at risk for continued abuse. The Administrator became aware of the incidents only after receiving anonymous letters, at which point the accused CNA was suspended and subsequently terminated. Additionally, the facility failed to submit a final investigation report to the State Agency within five working days for a separate allegation of verbal abuse involving another resident. The Administrator and DON acknowledged that the final report was not sent due to the DON's illness and oversight, despite being aware of the requirement. This failure to report and investigate in a timely manner was determined to be Immediate Jeopardy and Substandard Quality of Care.
Removal Plan
- Quality Assurance (QAPI) Committee met to review, develop, and implement the facility policy on abuse and neglect with an emphasis on reporting abuse and neglect and to determine the root cause. The root cause was determined to be that employees were afraid of retaliation from other employees. Attendees included the Executive Director, MDS nurse, Medical Records, Regional Director of Clinical Services, Assistant Director of Nursing, Medical Director, Social Services, Staff Development/Infection Preventionist nurse, Activities Director, Human Resources, Housekeeping, Dietary Manager, Therapy director, Unit Managers, and the Admission Coordinator. No changes were made to the policy and procedure. The areas discussed were the re-education of staff members on the abuse and neglect policy with an emphasis on reporting requirements and that failure to do so is a crime.
- Body audits were completed on Resident #1 and Resident #2 by the Staff Development nurse and a licensed nurse. No signs of physical abuse were identified.
- Interviews were conducted by Social Services Director with alert and oriented residents on side 2. No residents voiced complaints of abuse.
- The physician and the Resident Representatives of Resident #1 and Resident #2 were notified.
- Education was started by the Staff Development Nurse.
- Quality Assurance Performance Improvement Committee met to review the physical and verbal abuse.
- Social Services completed a psychosocial follow up with Resident #1 and Resident #2.
- 100% body audits were performed on all facility residents by the unit manager RN and the Minimum Data Set nurses to ensure that residents did not have physical signs of abuse. No residents were identified.
- The Executive Director was educated on the abuse policy by the Regional Director of Clinical Services and timely reporting of abuse within 2 hours to the state agency, attorney general, and the abuse and neglect policy.
- The Social Services Director and the Admissions Coordinator interviewed all alert and oriented residents (census) using the Risk Management Quality Improvement Questionnaire to determine if any residents had been abused or witnessed abuse. There were no residents that voiced any complaints of abuse.
- The Staff Development nurse started education with licensed nurses, CNAs, and non-direct care staff on the abuse and neglect policy and procedure with an emphasis on reporting requirements and 100% was completed.
- All facility staff members were interviewed by the Executive Director, Human Resources, and Assistant Director of Nursing by phone to ask if they ever witnessed any employee abuse a resident and explained the process of what to do if they ever witness abuse or neglect, with an emphasis on reporting requirements and that failure to do so is a crime.
- CNA #2 received one on one education on the abuse policy and the reporting requirements with an emphasis placed on the fact of not reporting being a crime.
- New hires will be educated during orientation.
Failure to Implement Comprehensive Care Plan Interventions for Resident with Behavioral Needs
Penalty
Summary
The facility failed to implement comprehensive care plan interventions for a resident with diagnoses including Parkinson's Disease and dementia, who exhibited behaviors such as occasional physical and verbal aggression. The resident's care plan, revised to address these behaviors, included specific interventions such as intervening before agitation escalates, guiding the resident away from distress, engaging calmly in conversation, and, if aggression occurred, staff were to walk away and return later. Despite these documented interventions, staff did not follow the care plan during an incident where the resident became agitated and physically aggressive during incontinence care. During the incident, a CNA held the resident's hands and attempted to reassure her, but the resident pulled away and grabbed another CNA by the hair. In response, the second CNA grabbed the resident's nose and twisted it, causing a nosebleed, and made an inappropriate comment. Interviews with staff and facility leadership confirmed that the care plan was not followed, as staff did not step away and allow the resident time to calm down before reattempting care, contrary to the established interventions for managing the resident's behaviors.
Insufficient Staffing Leads to Resident Left Soiled Overnight
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, resulting in a resident being left soiled throughout the night. On the overnight shift in question, only one CNA was present in the facility, despite the staffing grid indicating that more were needed. Three CNAs failed to call in for their shift, and attempts by the LPN on duty to contact the DON and the scheduler for assistance were unsuccessful. The LPN was given a list of potential replacements, but none were available, and no further support was provided by facility leadership. As a result of the staffing shortage, a resident with a diagnosis of overactive bladder and documented as always incontinent of urine was unable to receive timely incontinence care. The resident reported being left in urine for the entire night, causing discomfort. The resident was cognitively intact and able to clearly describe the incident, stating that the lack of staff directly led to her needs not being met.
Facility Assessment Lacks Required Staffing Details and Contingency Planning
Penalty
Summary
The facility failed to include all required elements in its Facility Assessment, specifically omitting detailed staffing needs by shift, a plan for recruitment and retention of staff, and contingency planning for situations that do not require activation of the emergency operations plan. The Facility Assessment only identified total staffing numbers needed over a 24-hour period and did not specify requirements for each eight-hour shift or account for changes in the resident population. During an interview, the Administrator acknowledged a lack of awareness regarding the federal requirement to address staffing by shift and confirmed the assessment's deficiencies. Additionally, a resident interview revealed that on one overnight shift, only one CNA was present, resulting in the resident being left in urine throughout the night due to insufficient staff coverage. The resident, who has an overactive bladder and is always incontinent of urine, expressed discomfort and noted the absence of contingency plans for staffing shortages. Review of facility records confirmed the resident's medical condition and the staffing grid for the shift in question, substantiating the reported deficiency.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that daily nurse staffing information was posted in a visible and accessible location for two out of three survey days. Observations on multiple occasions revealed that the required staffing postings were not present in the designated area near the copier room in a glass case, nor was an alternative posting location identified. Interviews with LPNs and the Director of Nursing confirmed that the staffing information was not posted as required, and a review of facility records showed that postings were missing for the specified days. The Administrator acknowledged that the postings were not present for the previous two days and attributed the lapse to an oversight, despite internal tracking of staffing. The absence of posted staffing information limited residents, family members, and the public from accessing required information and impeded transparency regarding facility staffing levels, as confirmed by staff interviews and record review.
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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