Tupelo Community Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Tupelo, Mississippi.
- Location
- 1901 Briar Ridge Road, Tupelo, Mississippi 38804
- CMS Provider Number
- 255136
- Inspections on file
- 25
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Tupelo Community Care Center during CMS and state inspections, most recent first.
A resident in a rehabilitation unit was verbally abused by an LPN for reporting delayed pain medication administration. The resident, cognitively intact and admitted for a tibia fracture, was confronted harshly by the LPN, causing emotional distress. Witnesses, including therapy staff, confirmed the LPN's demeaning behavior, and trauma assessments documented the resident's emotional harm.
The facility failed to provide dementia care training to staff before they began caring for residents with dementia. Interviews revealed that CNAs had not received such training, and the Staff Development Nurse confirmed it was not part of the new hire orientation. The facility's records showed no policy or inclusion of dementia care in the New Hire Program, despite having residents diagnosed with Dementia and/or Alzheimer's Disease.
The facility did not ensure that handrails in resident hallways were securely affixed, affecting all four hallways. Observations showed multiple loose handrails, and the Administrator confirmed they had been loose for some time, acknowledging a potential safety issue. The handrails were made of PVC pipes, and while replacement was considered, floor replacement was prioritized. Communication about fixing the handrails was noted from May, but corporate approval was pending. The facility lacked a policy on repairs.
The facility failed to provide dementia care training to new hire staff before they began caring for residents with dementia. Interviews revealed that CNAs had been working for months without such training, and the Staff Development Nurse confirmed that dementia care was not part of the new hire orientation. The Administrator acknowledged the need for this training, given the number of residents with dementia in the facility.
The facility was found deficient in managing resources and providing adequate care. Issues included broken equipment, lack of dementia care training, and inadequate hygiene care for residents. Several residents did not receive proper baths, nail trimming, or shaving. Equipment maintenance was poor, with loose handrails and damaged wheelchairs posing safety risks. The administration failed to address these issues effectively, with inadequate communication and follow-up from staff.
The facility's QAPI/QAA committee failed to maintain and monitor interventions, resulting in repeated deficiencies in ADL care, psychotropic medication monitoring, and infection control. Despite efforts to implement a Performance Improvement Plan, issues persisted due to ineffective communication, lack of accountability, and oversight within the facility.
The facility failed to monitor side effects of psychotropic medications for three residents, despite policy requirements. Residents with major depressive disorder, generalized anxiety disorder, and dementia were prescribed multiple psychotropic drugs without documented side effect monitoring. Interviews with staff confirmed the absence of routine monitoring, highlighting a significant oversight in resident care.
A resident returned from the hospital with a C-Diff infection and was not placed on contact isolation precautions, despite having a physician's order for treatment. Observations showed no isolation measures in place, and interviews with staff confirmed the oversight. The DON and Infection Control nurse acknowledged the resident should have been isolated to prevent infection spread.
The facility failed to implement care plans for personal hygiene and incontinence care for several residents, leading to unmet needs. A resident with mild cognitive impairment did not receive shaving assistance, while another with moderate impairment had untrimmed, dirty nails. Cognitively intact residents reported not receiving regular baths or timely incontinence care, with observations confirming these deficiencies. Staff acknowledged the care plans were not followed.
The facility failed to provide adequate ADL assistance and incontinent care for several residents. A resident with mild cognitive impairment did not receive requested facial hair removal, while another with moderate impairment had untrimmed, dirty nails. A double amputee resident reported irregular bathing, confirmed by staff and documentation. Incontinent care was insufficient for three residents, with reports of being left in soiled conditions and delays in care. The DON acknowledged these failures, highlighting a lack of consistent care and communication within the facility.
The facility failed to provide adequate care for several residents, resulting in unmet personal hygiene needs and neglect. A resident's request for facial hair removal was ignored, while another did not receive a bath for several days. A resident was left in soiled conditions due to ignored call lights, and another had long, dirty fingernails. Staff interviews revealed chronic understaffing, with aides overwhelmed by numerous responsibilities, leading to inadequate care.
A resident in a LTC facility was unable to receive coffee for a month due to a broken coffee machine, impacting her right to self-determination and choice. The issue was raised in a Resident Council meeting, and staff interviews revealed that a temporary method of making coffee caused delays. The resident, who was cognitively intact, expressed that coffee was a significant social activity, and the lack of it affected her and other residents.
A facility failed to provide timely written notification of a hospital transfer for a resident, as required by their policy. The resident, who was cognitively intact, was transferred due to chest pains, but the Discharge/Transfer notice lacked a signature and proof of mailing to the resident's representative. The representative confirmed not receiving any notification.
A facility failed to provide a resident and their representative with written notice of the bed-hold policy during a hospital transfer. The resident, who was cognitively intact, was unaware of the policy, and the representative confirmed not receiving any notice. The Business Office Manager could not prove that the notice was mailed, despite the facility's policy requiring such notification.
A resident was inaccurately coded in the MDS as receiving insulin injections, despite not being diabetic and having no record of insulin administration. The MDS Nurse confirmed the error, and the facility's policy requires accurate assessments to reflect residents' conditions.
A resident's wheelchair was found to have exposed foam on both armrests due to cracked protective covering, which had been in this condition for some time. The resident, who was cognitively intact, reported the roughness of the exposed areas. The DON confirmed the need for replacement to prevent skin injury and acknowledged the oversight in the repair system. The resident had diagnoses of muscle wasting, atrophy, muscle weakness, and cerebral infarction.
A facility failed to maintain a clean environment in a resident's room, where a fall protection floor mat was found covered in stains. Despite daily cleaning protocols, the mat remained unclean, and the facility lacked a specific policy for cleaning such mats. Staff interviews confirmed the necessity of daily cleaning to prevent infection spread.
Resident Verbal Abuse by LPN
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a staff member, specifically an LPN, who confronted the resident for reporting not receiving pain medications in a timely manner. The resident, who was cognitively intact with a BIMS score of 15, was admitted for short-term rehabilitation following a tibia fracture. The incident involved the LPN speaking harshly and in a demeaning tone to the resident, which was witnessed by other staff members, including a Speech Therapist and a Physical Therapy Assistant. These staff members provided written statements corroborating the resident's account of the LPN's confrontational behavior. The resident reported feeling emotionally unsafe and was visibly upset, crying after the encounter with the LPN. The resident had a history of requesting pain medications prior to therapy sessions, which were not administered in a timely manner, leading to the confrontation. The resident expressed that the LPN's behavior was the worst she had experienced, despite her background as a former City Police Officer. The resident's emotional distress was further documented in trauma assessments conducted by a Licensed Social Worker, which confirmed the resident's trauma following the incident. Interviews with other staff members, including CNAs and the Director of Rehabilitation, supported the resident's claims of the LPN's inappropriate conduct. The facility's investigation concluded that while abuse was not substantiated, the LPN exhibited poor customer service. However, the evidence from staff interviews and written statements indicated that the LPN's actions were perceived as abusive by the resident and other staff members, highlighting a failure to ensure the resident's right to be free from abuse.
Lack of Dementia Care Training for Staff
Penalty
Summary
The facility failed to ensure that staff were trained on dementia care before caring for residents with dementia. This deficiency was identified during a survey, where it was found that the facility did not have a policy on training staff or assessing their competency in dementia care. Interviews with Certified Nurse Assistants (CNAs) revealed that they had not received any training on dementia care, despite working at the facility for about four months. The Staff Development Nurse confirmed that dementia care training was not part of the new hire orientation, and the Administrator acknowledged that staff should receive such training due to the number of residents with dementia. The facility's records showed that the last dementia care in-services were conducted in August and October of the previous year, and the New Hire Program did not include dementia care training. The Facility Assessment Tool also did not list dementia care as a required topic for new hires. The Resident Matrix indicated that there were 16 residents with a diagnosis of Dementia and/or Alzheimer's Disease, with two residing on the B Hall. This lack of training and policy implementation led to a deficiency in the care provided to residents with dementia.
Loose Handrails in Resident Hallways
Penalty
Summary
The facility failed to ensure that handrails in the resident hallways were permanently affixed to the walls, affecting all four hallways. Observations on September 9, 2024, revealed multiple loose handrails with their ends not securely attached to the walls. During an interview, the Administrator confirmed that the handrails had been loose for some time and acknowledged that they could pose a safety issue for residents. The Administrator mentioned that the handrails were made of PVC pipes and that they had been considering replacing them, but prioritized floor replacement first. Communication from a company regarding options for fixing the handrails was noted from May 10, 2024, but approval from corporate had not yet been obtained. The facility also lacked a policy on facility repairs, as indicated by a statement from the Executive Director dated September 11, 2024.
Lack of Dementia Care Training for New Hires
Penalty
Summary
The facility failed to ensure that new hire staff were trained on dementia care before caring for residents with dementia. This deficiency was identified during a survey where it was found that the facility did not have a policy on training staff or assessing their competency in dementia care. Interviews with two Certified Nurse Assistants (CNAs) revealed that they had been working at the facility for about four months without receiving any training on dementia care. One CNA mentioned that she was unaware of any special considerations for dealing with residents with dementia, although she did not have any residents with such a diagnosis in her assigned area. Further interviews with the Staff Development Nurse and the Administrator confirmed that dementia care training was not part of the new hire orientation. The Staff Development Nurse, who had been in her role for about five years, acknowledged that dementia care training had never been included in the orientation process. The Administrator also confirmed that staff should receive dementia care training due to the significant number of residents with dementia in the facility. A review of the New Hire Program and the Facility Assessment Tool corroborated the absence of dementia care as a required training topic, despite the presence of 16 residents diagnosed with dementia or Alzheimer's Disease in the facility.
Deficiencies in Resident Care and Facility Management
Penalty
Summary
The facility was found to be deficient in several areas during a survey conducted over three days. The administration failed to manage resources effectively, as evidenced by the lack of a policy on administration or administrative staff, and the absence of dementia care training in new hire orientation. The facility's Executive Director and Director of Nursing (DON) were unaware of several ongoing issues, including broken equipment and inadequate care for residents, which were not addressed in a timely manner. For instance, the coffee maker used for residents had been broken for about two months, causing delays in service, and the facility's handrails had been loose for a while, posing a safety risk. The survey revealed multiple instances of inadequate care for residents. Several residents did not receive proper hygiene care, such as regular baths, nail trimming, and shaving, which are essential for their well-being. Resident #43 did not receive assistance with shaving, and Resident #59 complained about not having a bath since the previous Tuesday. Additionally, Resident #68 experienced delays in receiving incontinent care, and Resident #352 was often found soiled during therapy sessions, indicating a lack of timely care by the staff. The DON admitted that aides were expected to make rounds every two hours, but this was not consistently happening. The facility also failed to maintain equipment and the environment in a safe and sanitary condition. Resident #84's wheelchair arms needed replacement to prevent skin injury, and the facility's handrails were loose, which could lead to accidents. The DON and Administrator acknowledged these issues but had not implemented effective measures to address them. The lack of communication and follow-up was evident, as the DON relied on charge nurses and unit managers to ensure tasks were completed, but this oversight was insufficient. The facility's performance improvement plan did not address the root causes of these deficiencies, leading to ongoing issues with resident care and safety.
Repeated Deficiencies in ADL Care and Monitoring
Penalty
Summary
The facility's Quality Assessment Performance Improvement (QAPI)/Quality Assessment and Assurance (QAA) committee failed to maintain and monitor the interventions they had implemented, leading to repeated deficiencies in several areas. These deficiencies were initially cited during a recertification survey on May 18, 2023, and were found again during a subsequent survey on September 9, 2024. The repeated deficiencies included failure to implement an Activities of Daily Living (ADL) care plan, assist residents with ADLs, monitor for side effects of psychotropic medications, and place an infectious resident in contact isolation. The facility's inability to sustain an effective Quality Assurance Program was evident as these issues persisted across multiple surveys. Interviews with the Director of Nurses (DON) and the Administrator revealed a lack of effective communication and follow-up within the facility. The DON admitted to relying on charge nurses and Unit Managers to ensure tasks were completed, but acknowledged that this did not always happen. The Administrator confirmed that staffing concerns, ADL care, or care plans were not addressed during QAPI/QAA meetings. Despite efforts to implement a Performance Improvement Plan (PIP) and assign administrative nurses and Unit Managers to monitor resident care, no significant issues were identified or addressed. Both the DON and Administrator recognized a lack of accountability and oversight, contributing to the ongoing deficiencies.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to ensure residents were free from unnecessary drug use by not monitoring for side effects of psychotropic medications for three residents. The facility's policy required routine review and monitoring for side effects of these medications, but this was not adhered to. Resident #44, who was admitted with major depressive disorder and generalized anxiety disorder, was prescribed multiple psychotropic medications, including Duloxetine, Quetiapine Fumarate, Lorazepam, and Divalproex Sodium. Despite these prescriptions, there was no evidence of side effect monitoring. Similarly, Resident #54, with severe cognitive impairment and diagnoses including dementia with psychotic disturbance and major depressive disorder, was on a regimen of psychotropic medications such as Quetiapine Fumarate, Memantine, and others, yet lacked documented side effect monitoring. Resident #87, admitted with generalized anxiety disorder and major depressive disorder, was also prescribed several psychotropic medications, including Buspirone, Fluoxetine, and Trazodone, without any monitoring for side effects. Interviews with facility staff, including a registered nurse and the Director of Nursing, confirmed the absence of routine monitoring for side effects. The Pharmacy Consultant emphasized the importance of monitoring for adverse reactions, such as over-sedation, to determine if medication adjustments were necessary. This lack of monitoring represents a significant oversight in the care of residents receiving psychotropic medications.
Failure to Implement Contact Precautions for C-Diff Infection
Penalty
Summary
The facility failed to implement appropriate infection prevention and control measures for a resident who returned from the hospital with a Clostridium Difficile Colitis (C-Diff) infection. Despite having a physician's order for Fidaxomicin to treat C-Diff, the resident was not placed on contact isolation precautions upon their return. Observations revealed the absence of isolation barrels and signage indicating contact precautions in the resident's room. Interviews with the resident and staff confirmed the oversight, with the Licensed Practical Nurse (LPN) acknowledging that the resident was not on contact precautions and should have been. The Director of Nursing and the Assistant Director of Nursing/Infection Control nurse both confirmed that the resident should have been placed on contact isolation to prevent the spread of infection. The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, had been admitted to the facility with a diagnosis of Chronic Obstructive Pulmonary Disease and had a history of long-term antibiotic use. The failure to implement contact precautions was a clear deviation from the facility's policy and the Centers for Disease Control (CDC) guidelines for managing C-Diff infections.
Failure to Implement Care Plans for Personal Hygiene and Incontinence Care
Penalty
Summary
The facility failed to implement developed care plans for several residents, leading to unmet personal care needs. Resident #43, who has a mild cognitive impairment, expressed a preference for facial hair removal by shaving, which was not provided despite being part of her care plan. The Director of Nursing and the MDS Assistant confirmed that the care plan, which included shaving as part of the bathing routine, was not followed. Resident #151, with moderate cognitive impairment, had a care plan for nail care that was not implemented. The resident's fingernails were observed to be long and dirty, and she expressed a desire for them to be trimmed. The Director of Nursing confirmed the care plan for nail care was not followed, and the MDS Assistant acknowledged the failure to implement the care plan. Residents #59, #68, #351, and #352 experienced deficiencies in bathing and incontinent care. Resident #59, who is cognitively intact, reported not receiving regular baths as per his care plan. Resident #68, also cognitively intact, was left in wet clothing for an extended period, and Resident #351 was observed in urine-soaked clothing. Resident #352, who is cognitively intact, reported delays in receiving incontinence care, corroborated by a Physical Therapy Assistant who noted consistent issues with the resident being soiled during therapy sessions. The MDS Nurse confirmed that the care plans for these residents were not followed.
Deficiencies in ADL Assistance and Incontinent Care
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADLs) for several residents who were dependent on staff. Resident #43, who had a mild cognitive impairment, expressed a preference for facial hair removal, which was not fulfilled by the staff despite her requests. Observations confirmed the presence of facial hair, and the Director of Nursing (DON) acknowledged the failure to provide the necessary grooming care. Similarly, Resident #151, with moderate cognitive impairment, had long, dirty fingernails, and despite expressing a desire for nail care, the facility did not address this need. Resident #59, a double above-knee amputee, reported not receiving regular baths, stating he had not been bathed since the previous Tuesday. The resident required assistance with bathing, and documentation confirmed missed bathing schedules. Staff interviews revealed that the resident only received baths when a specific CNA was on duty, and complaints made to an LPN were not escalated or addressed. This lack of consistent bathing care was acknowledged by the staff involved. Incontinent care was also inadequately provided for Residents #68, #351, and #352. Resident #68, who was cognitively intact, reported being left in soiled conditions over the weekend, with staff failing to return after turning off the call light. The DON confirmed the incidents and the failure to provide timely care. Resident #351 was observed in wet clothing, with family members reporting consistent issues with incontinence care. The DON was unaware of these concerns until recently. Resident #352 experienced delays in being changed, with therapy staff noting the issue during sessions. The DON was not informed of these delays, indicating a communication breakdown within the facility.
Inadequate Staffing Leads to Neglect in Resident Care
Penalty
Summary
The facility failed to provide adequate nursing care for six out of seven residents reviewed for Activities of Daily Living (ADL) during the survey. Resident #43 expressed a preference for facial hair removal, which was not attended to by the staff despite multiple requests. Similarly, Resident #59, a double above-knee amputee, reported not receiving a bath since the previous Tuesday, and this was confirmed by the Certified Nurse Assistant (CNA) assigned to him. The documentation corroborated that the resident did not receive a bath on the specified date, highlighting a lapse in personal hygiene care. Resident #68 experienced neglect over a weekend when her call light was ignored, leaving her in soiled conditions for an extended period. The Director of Nursing (DON) acknowledged awareness of the incidents and took disciplinary actions against the aides involved. However, the resident reported that the aides did not check on her every two hours as expected. Resident #151 also suffered from neglect, with long fingernails and a brown substance under them, which the DON confirmed should have been addressed to prevent infections. Additional issues were observed with Resident #351, who was found in a urine-soaked state after returning from therapy, and Resident #352, who experienced delays in being changed after meals, affecting his therapy sessions. Interviews with staff revealed chronic understaffing, with aides responsible for numerous tasks and residents, leading to inadequate care. The facility's staffing policy based on resident acuity was insufficient to meet the needs of the residents, as evidenced by the numerous complaints and observations of neglect.
Resident's Right to Coffee Denied Due to Broken Machine
Penalty
Summary
The facility failed to ensure a resident received coffee as desired, which is a violation of the resident's right to self-determination and choice. The deficiency was identified through observation, resident and staff interviews, and record reviews. A resident expressed that she had not received coffee for the past month due to a broken coffee machine in the kitchen. This issue was also raised during a Resident Council meeting, where residents were informed that the coffee machine was being repaired. The resident emphasized that coffee was a significant social activity for her and other residents, and the lack of it had negatively impacted their experience. Interviews with the Dietary Manager and the Administrator revealed that the coffee machine had been broken for about two months, and a temporary method of boiling water and using a filter was implemented, which caused delays in serving coffee to residents. The Dietary Manager acknowledged the residents' complaints and frustration, and the Administrator confirmed awareness of the issue but underestimated the duration of the problem. The Administrator also mentioned that a backup method was in place but was unaware of the delays it caused. The resident involved was cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 15.
Failure to Notify Resident and Representative of Hospital Transfer
Penalty
Summary
The facility failed to provide timely written notification of a discharge/transfer to the hospital for Resident #45, as required by their policy. The policy, titled 'Emergency Transfers Procedures,' mandates that an Emergency Transfer notice, including the date, reason for transfer, location, and contact information for State Agencies to initiate the appeal process, should be provided to the resident or their representative as soon as practicable. However, during a review, it was found that the Discharge/Transfer notice for Resident #45 was dated a day after the transfer and lacked a signature from either the resident or their representative. Interviews and record reviews revealed that the Business Office Manager admitted to mailing the forms to the responsible party but had no proof of mailing. The resident's representative confirmed not receiving any notification regarding the discharge/transfer. Resident #45, who was cognitively intact with a BIMS score of 15, was transferred to the emergency department due to chest pains. The facility admitted Resident #45 in December 2022 with a diagnosis related to urinary tract care, and the failure to notify the resident or their representative in writing of the hospital transfer was identified as a deficiency.
Failure to Provide Bed-Hold Notice
Penalty
Summary
The facility failed to provide written notice of the bed-hold policy to a resident and their representative during a transfer to a hospital. This deficiency was identified for one of three residents reviewed for bed holds. The facility's policy, titled F-625 Notice of Bed-Hold Policy, requires that at the time of a resident's transfer for hospitalization, the nursing facility must provide written notice of the bed-hold policy to both the resident and their representative. However, in the case of Resident #45, this procedure was not followed. Resident #45, who was admitted to the facility with a diagnosis related to urinary tract care, was transferred to the hospital without receiving the required bed-hold notice. During an interview, the resident stated she was unaware of the bed-hold policy. A review of the Bed-Hold Notice form for this resident showed a date of notice but lacked a signature from either the resident or their representative. The Business Office Manager admitted that the notices are mailed out but could not provide proof that the notice was sent. The resident's representative confirmed that they had never received any bed-hold notice, despite the resident having been hospitalized multiple times.
Inaccurate MDS Coding for Insulin Administration
Penalty
Summary
The facility failed to accurately complete section N of the 5-day Minimum Data Set (MDS) for one of the sampled residents. Specifically, Resident #22 was incorrectly coded as having received insulin injections for seven days during the 7-day look-back period since admission. However, upon review of the Medication Administration Record (MAR) for August 2024, it was found that Resident #22 did not receive insulin or any injections during this period. An interview with the resident confirmed that he was not diabetic and had never taken insulin injections. The MDS Nurse acknowledged the coding error, confirming that Resident #22 did not have a physician order for insulin. The facility's policy on MDS Assessment, revised in June 2023, mandates that assessments be conducted accurately to reflect the resident's condition and facilitate the development of an individualized care plan. The Administrator expressed that her expectation was for MDS assessments to be completed accurately. Resident #22 was admitted to the facility with a diagnosis of Chronic Obstructive Pulmonary Disease and had a Brief Interview for Mental Status (BIMS) score indicating moderate cognitive impairment.
Wheelchair Maintenance Deficiency
Penalty
Summary
The facility failed to ensure a wheelchair was in good, safe condition for one of the sampled residents. During an observation, it was noted that the wheelchair of Resident #84 had both armrests with foam exposed due to cracked protective covering. The left armrest was entirely affected, and the right armrest had a damaged area approximately four inches by one inch. Resident #84, who was cognitively intact with a BIMS score of 15, reported that the wheelchair had been in this condition for a while and that the exposed areas were rough to touch. The Director of Nursing confirmed that the wheelchair arms needed replacement to prevent potential skin injury and acknowledged that the issue was overlooked and not entered into their repair system. The resident had been admitted with diagnoses including muscle wasting, atrophy, muscle weakness, and cerebral infarction.
Failure to Maintain Clean Environment in Resident Room
Penalty
Summary
The facility failed to maintain a clean and homelike environment in one of the observed rooms, specifically room D5 B. During an observation, a fall protection floor mat was found to be covered in black and brown dried stains, and a clump of a brown leaf tobacco product was observed on the floor next to the mat. Although the tobacco product was cleaned up later, the floor mat remained stained. The facility lacked a policy on cleaning floor mats, as revealed by a document signed by the Executive Director. Interviews with staff, including a CNA, the DON, a housekeeper, and the Assistant Director of Nursing/Infection Control Nurse, confirmed that the floor mats should be cleaned daily to prevent infection spread. The CNA acknowledged the mat was filthy, and the DON emphasized the importance of daily cleaning. The housekeeper stated that resident rooms are cleaned daily, including mopping under mats and sanitizing the top of mats. The Assistant Director of Nursing/Infection Control Nurse reiterated the need for daily cleaning and sanitization of the mats to reduce infection risk.
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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