Woodlands Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Clinton, Mississippi.
- Location
- 102 Woodchase Park Drive, Clinton, Mississippi 39056
- CMS Provider Number
- 255148
- Inspections on file
- 26
- Latest survey
- August 15, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Woodlands Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Surveyors observed two medication administration errors, resulting in a medication error rate above 5%. One resident was not instructed to rinse their mouth after receiving a steroid inhaler, and another was nearly given an incorrect dose of Thiamine by an LPN, contrary to physician orders. The DON confirmed the importance of following proper medication administration procedures.
Staff failed to follow infection prevention and control protocols during care for three residents, including not performing hand hygiene between glove changes, not wearing gowns as required by Enhanced Barrier Precautions, and using contaminated gloves to handle supplies. These lapses occurred during wound care, perineal care, and PEG site care for residents with pressure ulcers and severe cognitive impairment.
A resident with a diagnosis of dementia, but who was cognitively intact, was not informed of their right to formulate an advance directive (AD) nor offered assistance in doing so. Review of the clinical record and confirmation by an LPN showed no documentation of this required process, and the Administrator acknowledged that no steps had been taken to address the lack of an AD after it was identified during a care plan conference.
A resident with a feeding tube and a history of hemiplegia and hemiparesis did not receive care in accordance with their care plan, which required Enhanced Barrier Precautions. During observed peri care, a CNA failed to wear a protective gown as specified in the care plan, despite having received EBP training. The RN confirmed that the care plan was not followed during this incident.
A resident with a history of syncope and coded as dependent for transfers was left unsafely supervised during a shower transfer when a CNA, unfamiliar with the resident, attempted to transfer the resident alone despite visible weakness and shaking. The CNA did not follow the care plan or seek help, and the DON confirmed that proper transfer protocols were not followed.
A resident with End Stage Renal Disease repeatedly arrived late to scheduled dialysis appointments due to transportation delays and unclear communication about chair times, resulting in multiple shortened dialysis sessions over the course of a month. Staff interviews and documentation confirmed ongoing issues with van availability and coordination with the dialysis clinic, leading to incomplete treatments for the resident.
A medication prescribed for a resident with acute and chronic respiratory failure was found unattended and unsecured on a bedside table, contrary to facility policy requiring all medications to be stored in locked compartments. The DON confirmed that staff should not leave medications in resident rooms and that the resident was not able to self-administer the inhaler.
A resident's medical record lacked documentation regarding the presence, refusal, or offer of assistance for an advance directive (AD). An LPN and the Administrator confirmed that no such information was available in the electronic health record, and the resident, who was cognitively intact and had no POA or AD, had lived in the facility for several years. No steps were taken to document the AD status after it was identified as missing during a care plan conference.
The QAPI Committee failed to prevent recurrence of a medication error rate above 5%, as evidenced by two medication errors out of 31 opportunities, including a resident not instructed to rinse after a steroid inhaler and another given an incorrect Thiamine dose. This repeated deficiency occurred despite previous citations and ongoing committee meetings.
A resident with severe cognitive impairment left an LTC facility unsupervised after a transportation aide allowed them to exit through the front door. The resident was later found across the street, unsupervised for approximately 13 minutes. The facility's failure to provide adequate supervision and implement its wanderer management policy led to this Immediate Jeopardy and Substandard Quality of Care incident.
A resident in a long-term care facility was physically and emotionally abused by a CNA, who handled the resident roughly, sprayed cold water on his face, and turned off the lights in the shower room while laughing. The incident was witnessed by an LPN who intervened, but the facility failed to act promptly, allowing the CNA to continue working for several days. The resident reported feeling sad and taken advantage of, and the facility's delay in addressing the abuse led to a determination of Immediate Jeopardy and Substandard Quality of Care.
A resident experienced physical and emotional abuse by a CNA, which was witnessed by an LPN. The incident involved rough handling during care, including spraying the resident with cold water and turning off the lights. Despite the LPN reporting the incident to the charge nurse and Administrator, the facility failed to report it to the State Agency within the required timeframe, increasing the risk of harm.
The facility failed to ensure a clean and homelike environment for three residents, resulting in strong urine odors and unsanitary conditions in their rooms. A resident's room had a strong urine odor due to a wet incontinence brief, while two residents in a shared room experienced similar issues with a urinal and spilled urine. Staff interviews confirmed the odors and the need for immediate cleaning, highlighting a failure to provide timely and adequate care for residents with various medical conditions.
Two residents in a facility did not receive care as outlined in their comprehensive care plans, leading to deficiencies. One resident was left in a saturated incontinence brief for over two hours, while another was found sitting on a soaked incontinence pad with a strong urine odor in the room. Both residents required assistance with personal hygiene and toileting, which was not adequately provided.
Two residents in an LTC facility did not receive timely incontinence care as required. One resident was found with a saturated brief, and the CNA admitted to not checking for over two hours. Another resident had a soaked incontinence pad, with care delayed for nearly three hours. Both residents required assistance due to their medical conditions, and staff confirmed the expectation of two-hourly rounds was not met.
A facility failed to maintain a mechanical lift in safe working condition, leading to a malfunction during a resident transfer. Staff attempted to resolve the issue by replacing batteries, but the lift only worked when the battery was manually squeezed into place. Interviews revealed a lack of communication and reporting of the malfunction, and the Maintenance Director had not received any work orders for the lift. The resident involved had a history of cerebrovascular disease, repeated falls, and malignant neoplasm of the bladder.
A resident admitted with severe hip pain did not receive timely pain management due to the facility's failure to notify the physician, as required by policy. Despite reporting pain at a level 9 out of 10, the resident did not receive pain medication until hours later, and the nurse did not inform the primary healthcare provider of the resident's condition.
A resident who had undergone hip replacement surgery reported severe pain upon admission to the facility, but did not receive pain medication until over five hours later. Despite having a prescription for Oxycodone-Acetaminophen, the nursing staff failed to administer the medication in a timely manner or notify the primary healthcare provider about the unrelieved pain. The facility's policies for pain management were not followed, resulting in a delay in addressing the resident's pain.
A facility failed to follow physician orders and dialysis aftercare communication for a resident with an AV shunt. Despite instructions to remove the pressure dressing within a specified timeframe, the resident returned from dialysis with the dressing still in place. Communication issues between the dialysis unit and facility staff contributed to this deficiency, as acknowledged by the DON.
A resident was discharged home with medications and home health services, but the MDS was incorrectly coded as a discharge to a short-term general hospital. The error was confirmed by the MDS Coordinator and DON, who acknowledged that the resident was discharged to live with her sister. The MDS was coded by an LPN, and the Administrator expected the MDS Coordinator to verify the coding accuracy.
A facility failed to conduct a PASRR Level II for a resident with Paranoid Schizophrenia who transitioned from short-term to long-term care. The resident was admitted for short-term therapy, but the necessary screening was not updated when their care status changed. Staff interviews revealed a lack of awareness about the requirement for a Level II PASRR referral.
A facility failed to maintain a medication error rate below 5%, resulting in an 8% error rate. An RN administered two different eye drops to a resident without waiting the required three to five minutes between applications, as per facility policy. The resident had orders for these drops following eye surgery. Despite attending an inservice on medication procedures, the RN only waited 20 seconds between administering the drops, leading to the error.
A CNA was observed carrying dirty linen against her clothes instead of using a leak-proof bag, contrary to the facility's infection control policy. The DON confirmed this action could lead to infections. Despite prior training, the CNA did not follow proper procedures.
The facility failed to update care plans for two residents, leading to deficiencies in their care. One resident's care plan lacked instructions for timely removal of a dialysis dressing, despite repeated communications from the dialysis unit. Another resident's care plan inaccurately indicated continuous tube feedings, although the order had changed to bolus feedings due to aspiration risk. These issues were not addressed until after the State Agency's entrance, revealing lapses in communication and documentation by nursing staff.
Medication Error Rate Exceeds Regulatory Threshold Due to Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required by policy, resulting in a 6.45% error rate during the survey period. Two medication errors were observed among 31 opportunities. In the first instance, an LPN administered Symbicort Inhalation Aerosol to a resident with a diagnosis of Toxic Encephalopathy and a BIMS score indicating cognitive intactness, but did not instruct the resident to rinse their mouth after administration. Both the LPN and the DON confirmed that mouth rinsing is necessary after using an inhaled corticosteroid to prevent oral thrush, and the medication guide also specifies this step. In the second instance, another LPN prepared an incorrect dosage of Thiamine for a resident admitted with a humerus fracture. The LPN placed a 100 mg Thiamine tablet in the medication cup, despite the physician's order specifying a 50 mg dose. The LPN later confirmed the error upon reviewing the medication label and removed the incorrect tablet. The DON acknowledged that medications must be administered according to physician orders and that incorrect dosing could result in negative outcomes. These observed actions directly contributed to the facility's medication error rate exceeding the regulatory threshold.
Failure to Adhere to Infection Prevention and Control Protocols During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple staff not adhering to established protocols during resident care. During wound care for a resident with pressure ulcers, a registered nurse changed gloves five times without performing hand hygiene between glove changes, contrary to facility policy and training. The nurse admitted to being unaware of the requirement for hand hygiene between glove changes, and the Director of Nursing confirmed this was a breach of infection control standards. In another instance, a certified nursing assistant provided perineal care to a resident with severe cognitive impairment without donning a gown, as required by Enhanced Barrier Precautions (EBP), and failed to perform hand hygiene between glove changes. The CNA also used contaminated gloves to retrieve additional wipes from a package and did not place a barrier on the table or gather all necessary supplies before starting care. The CNA acknowledged these lapses and stated she had received training on both hand hygiene and EBP but failed to follow procedures during the care. Additionally, a licensed practical nurse performed PEG site care for a resident with severe cognitive impairment without wearing a protective gown, as required by EBP. The LPN admitted to not wearing the gown and recognized this as an infection control issue. The Director of Nursing confirmed that a gown should have been worn during this procedure. These incidents demonstrate a failure to follow the facility's infection prevention and control policies during direct resident care.
Failure to Inform Resident of Advance Directive Rights and Provide Assistance
Penalty
Summary
The facility failed to ensure that a resident was informed of their right to formulate an advance directive (AD) and was provided assistance to do so, as required by facility policy. A review of the resident's clinical record showed no documentation that the resident had been informed about ADs or offered help in creating one. This was confirmed by an LPN in Medical Records, who verified that the resident's entire chart had been scanned into the electronic health record and contained no such documentation. The facility's policy requires informing residents about their rights regarding ADs and providing written information and assistance if requested. Further review revealed that the resident had been admitted several years prior with a diagnosis of unspecified dementia but was currently cognitively intact, as indicated by a BIMS score of 15 on the most recent MDS assessment. During a recent care plan conference, it was identified that the resident had no Power of Attorney or AD in place, and the Administrator confirmed that no steps had been taken since that time to inform the resident of their rights or offer assistance in formulating an AD.
Failure to Implement Enhanced Barrier Precautions per Care Plan
Penalty
Summary
The facility failed to implement care plan interventions related to Enhanced Barrier Precautions (EBP) for one resident who required these precautions due to the presence of a feeding tube. The resident's care plan specifically included the use of EBP, such as wearing a protective gown during high-contact care activities like changing briefs. During an observation, a Certified Nursing Assistant (CNA) was seen providing perineal care to the resident without wearing a protective gown, contrary to the care plan's interventions. Upon interview, the CNA acknowledged that she did not wear a gown during peri care and admitted she forgot to do so, despite having received training on EBP. The Registered Nurse responsible for care planning confirmed that the CNA did not follow the comprehensive care plan and reiterated that staff are expected to adhere to the care plan interventions. The resident involved had a history of hemiplegia and hemiparesis following an unspecified cerebrovascular disease and had been admitted to the facility with these diagnoses.
Failure to Provide Adequate Supervision and Assistance During Resident Bathing
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to provide adequate supervision and assistance to a resident during bathing activities. The resident, who had a diagnosis of syncope and collapse and was coded as dependent for transfers on the Minimum Data Set (MDS), was observed being transferred from a rolling shower chair to a wheelchair by a single CNA. During the process, the resident was visibly weak, with shaking arms, and was required to stand twice without additional staff present. The CNA did not seek help despite the resident's instability and did not use the call light, citing concerns about response time and the presence of a surveyor. The CNA also admitted to making transfer decisions based on observation rather than the care plan or Kardex instructions. Interviews with the CNA and the Director of Nursing (DON) confirmed that the resident required more assistance than was provided and that proper protocols for transfer and supervision were not followed. The DON stated that both the care plan and the CNA Kardex contained clear guidance on transfer status, which was not adhered to during the incident. The failure to follow established procedures and to seek appropriate assistance placed the resident at risk for accidents or injury during the bathing process.
Failure to Provide Timely Transportation for Dialysis Resulting in Shortened Treatments
Penalty
Summary
The facility failed to ensure that a resident requiring hemodialysis was transported in a timely manner to receive the full duration of prescribed dialysis treatment. The resident, who had a diagnosis of End Stage Renal Disease and a physician's order for dialysis three times a week at a specified chair time, consistently arrived late to her appointments. Interviews and record reviews revealed that the resident's late arrivals occurred on multiple occasions over the previous month, resulting in shortened dialysis sessions. The dialysis Nurse Manager confirmed that the resident's average arrival time was significantly later than scheduled, and that the clinic had to adjust her chair time, which sometimes led to early termination of treatment due to the clinic's closing time. Contributing factors included unclear communication regarding chair time changes between the dialysis clinic and the facility, as well as transportation issues such as facility vans being out of service and reliance on an external transport provider with a history of tardiness. The resident expressed frustration with the repeated changes and late arrivals, noting the impact on her treatment schedule. Staff interviews confirmed awareness of the transportation challenges and the expectation that residents be transported on time, but documentation showed that the resident continued to experience delays and incomplete dialysis sessions.
Unsecured Medication Left Unattended in Resident Room
Penalty
Summary
A medication storage deficiency occurred when a medication prescribed to a resident was found unattended on the bedside table during an observation. The medication, Dulera Inhalation Aerosol, was labeled with the resident's identifying information and dosage instructions but was not secured in a medication cart or locked storage area as required by facility policy. No staff were present in the room at the time of the observation. The resident involved had a diagnosis of acute and chronic respiratory failure with hypoxia and was cognitively intact, as indicated by a BIMS score of 13. Facility policy required all drugs and biologicals to be stored in a safe, secure, and orderly manner. The DON confirmed that nurses were not supposed to leave medications in residents’ rooms and stated that the resident would not be able to self-administer the inhaler.
Failure to Document Advance Directive Status in Medical Record
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident by not documenting whether the resident had an advance directive (AD) in place, declined to complete one, or was offered assistance to formulate one. A review of the resident's clinical record showed no documentation regarding the AD status. During an interview and review of the electronic health record, an LPN confirmed that there was no information about the resident's AD in the system, and if it was not scanned into the new system, it was not present in the building. The Administrator also confirmed that the resident's AD information was not readily available in the medical record. The resident in question had been admitted to the facility several years prior with a diagnosis of unspecified dementia and was found to be cognitively intact based on a recent BIMS score. A care plan conference was held with the resident, during which it was identified that the resident had no Power of Attorney (POA) or AD in place. Despite this, the facility had not taken steps to ensure that the resident's AD status was documented in the medical record.
Repeat Medication Error Rate Deficiency Due to Ineffective QAPI Oversight
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to sustain corrective actions to prevent recurrence of previously cited deficiencies related to medication error rates. During an annual recertification survey, the facility was cited for failing to maintain a medication error rate below 5%, and this deficiency was cited again during the current survey. Specifically, the facility had an 8% medication error rate in one survey and a 6.45% error rate in the most recent survey, both exceeding the regulatory threshold. The QAPI Committee, which is responsible for ongoing monitoring and oversight, did not ensure that corrective actions were effective in preventing the recurrence of this deficiency. Observations during the survey revealed two medication errors out of 31 opportunities. One resident was not instructed to rinse with water after receiving a steroid inhaler, and another resident received an incorrect dosage of Thiamine. These errors were identified through direct observation, record review, and staff interviews. The facility's policy and previous history of citations for the same issue were also reviewed, confirming that the deficiency persisted despite prior interventions.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent a vulnerable resident from leaving the premises unsupervised. On the morning of March 22, 2025, a resident with a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment, was allowed to exit the facility through the front door by a transportation aide. The resident was left unsupervised on the porch and subsequently wandered off the premises. A Licensed Practical Nurse (LPN) encountered the resident in the parking lot and attempted to redirect them back to the facility. However, the LPN left the resident unsupervised to seek additional help. During this time, the resident moved further away and was found across the street in a daycare parking lot, approximately one-fourth of a mile from the facility. The resident was unsupervised and out of sight for approximately 13 minutes, which posed a significant risk to their safety. The facility's policy on wanderer management and resident elopement protocol was not effectively implemented, as all staff are responsible for ensuring resident safety. The incident was determined to be an Immediate Jeopardy and Substandard Quality of Care, as the resident's unsupervised departure put them and other vulnerable residents at risk for serious harm.
Removal Plan
- LPN #1 assisted the resident to return to the facility.
- The Administrator was notified by RN #1 of Resident#1 exited the building without supervision and was back in the building.
- Resident#1 was placed on 1:1 monitoring.
- Resident#1 Responsible Party was notified by the DON that Resident#1 exited and had been returned to the facility.
- Nurse Practitioner (NP)#1 was notified by the Director of Nursing of Resident#1 exit of facility and return along with behaviors. NP#1 placed an order for behavioral unit evaluation of Resident#1 for inpatient stay.
- DON contacted Behavior facility with a referral for resident#1 for further evaluation.
- Resident# 1 refused a head-to-toe assessment but LPN #2 was able to visually inspect resident#1 during incontinence care. No injuries were noted.
- Resident#1 exited the facility with Behavioral Unit for inpatient stay.
- The State Agency (SA) was notified by the Director of Nurses of the incident.
- The SOC initiated a 100%, mandatory In-service Training for elopement (including facility policy review) and the care of residents with difficult behaviors, to be continued for all new hires going forward. No staff are allowed to work until in service completed.
- The DON completed a post Elopement wander evaluation on Resident #1 and changed to high risk for Elopement, and the care plan was updated to reflect this.
- DON reviewed the wander and elopement binders to ensure all were up to date.
- A Quality Assurance Committee Meeting was held with the Medical Director, Administrator, Director of Nursing/Infection Preventionist, and the Assistant Director of Nursing to discuss Resident #1 elopement along with plan of correction; policies were reviewed with no revisions. The facility procedure for residents sitting outdoors was updated.
- The Director of Nursing audited current high-risk wander patients to review orders and care plans for accuracy. There was currently one (1) wander patient. And the Administrator performed an elopement drill.
- The Maintenance director performed elopement drills with staff to review and educate on policies and procedures on elopement.
- A Staff quiz was initiated by the CNA # 2 with all staff on knowledge of the elopement policy.
- Resident council meeting was held by the Administrator to include the President and 19 members to notify of current events and procedure changes to outdoor sitting with supervision in ungated areas.
- New procedures were implemented by the Administrator related to residents prohibited from sitting in ungated areas without supervision.
- New procedures were placed in the new hire orientation package by the Administrator for implementation of the procedure change of residents prohibited from sitting in ungated areas without supervision.
- Wander evaluations were audited by the Director of Nursing on all current residents reveals six residents requiring schedule adjustments.
- The Director of Nursing will monitor current residents for potential risks through incident report reviews, observation and communication with staff; the Maintenance Director will conduct elopement drills monthly (with rotating shifts until all shifts completed). The Administrator will present incident report reviews and documentation of drills for review to QA team weekly to monitor compliance with the plan then quarterly.
Resident Abuse by CNA in LTC Facility
Penalty
Summary
The facility failed to protect a resident from physical and emotional abuse by a Certified Nursing Aide (CNA). The incident occurred when the CNA handled the resident roughly, sprayed cold water on his face, and turned off the lights in the shower room while laughing. This behavior was witnessed by a Licensed Practical Nurse (LPN) who intervened during the shower to prevent further harm. The resident, who was cognitively intact, reported feeling sad, taken advantage of, and a little afraid due to the incident. The abuse took place on December 25, 2024, but was not reported to the Director of Nursing (DON) until December 30, 2024. During this period, the CNA continued to work at the facility, which placed the resident and others at risk of ongoing harm. The LPN who witnessed the incident reported it to the charge nurse and later to the Administrator, but there was a delay in the facility's response to the allegations. The previous Administrator was informed of the incident but did not take immediate action to suspend the CNA or report the abuse to the State Agency (SA). The facility's failure to act promptly and remove the CNA from duty resulted in a determination of Immediate Jeopardy and Substandard Quality of Care. The State Agency was notified of the situation on February 3, 2025, and the facility was found to be in compliance after implementing corrective actions. However, the delay in addressing the abuse and the continued employment of the CNA after the incident highlighted significant lapses in the facility's abuse prevention and reporting protocols.
Delayed Reporting of Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse within the required two-hour timeframe for one of the sampled residents. A Licensed Practical Nurse (LPN) witnessed physical and emotional abuse of a resident on December 25, 2024, but the facility did not report it to the State Agency until December 30, 2024. This delay in reporting increased the risk of further harm to the resident and other residents, potentially leading to serious injury, harm, impairment, or death. The incident involved a Certified Nursing Assistant (CNA) who handled a resident roughly during activities of daily living care. The CNA sprayed the resident in the face with cold water, turned off the lights in the shower room, and roughly shook the resident's bed. The resident, who was cognitively intact with a Brief Interview for Mental Status score of 14, was admitted to the facility with diagnoses including hypertension and depression. The LPN who witnessed the incident reported it to the charge nurse and the Administrator, but the report was not acted upon in a timely manner. Interviews revealed discrepancies in the reporting process. The LPN stated she reported the incident immediately to the charge nurse and later to the Administrator, who instructed her to write a statement. However, the charge nurse and other staff members did not confirm hearing the report. The Administrator, who was on vacation, claimed the LPN's verbal report differed from the written statement. The Director of Nursing was unaware of the incident until December 30, 2024, when corporate inquired about the report, leading to the delay in notifying the State Agency.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for three residents, resulting in strong urine odors and unsanitary conditions in their rooms. Observations revealed that Resident #2's room had a strong urine odor due to a wet incontinence brief found in the trash can. Despite noticing the odor before 11:00 AM, a CNA did not locate the source or notify housekeeping, allowing the smell to persist throughout the day. Similarly, the shared room of Resident #3 and Resident #4 was found to have a strong urine odor, with a urinal and spilled urine under Resident #3's bed. A CNA discovered a non-disposable incontinence pad that was wet and stained, emitting a strong odor of urine and feces, indicating that Resident #3 had been sitting in the soiled pad for an extended period. Interviews with facility staff, including the Assistant Housekeeping Supervisor and the Director of Nursing, confirmed the presence of strong urine odors and the need for immediate cleaning to maintain a safe environment. The Housekeeping Supervisor noted that the floor in the shared room needed significant cleaning and possibly tile replacement due to the persistent odor. The residents involved had various medical conditions, including cerebral infarction, chronic kidney disease, and cognitive deficits, which required assistance with personal hygiene and toileting. Despite these needs, the facility staff failed to provide timely and adequate cleaning, compromising the residents' right to a safe and comfortable living environment.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to implement comprehensive care plan interventions for two residents, leading to deficiencies in their care. For the first resident, the care plan required extensive assistance with personal hygiene and incontinence care to prevent skin breakdown. However, an observation revealed the resident was left in a saturated incontinence brief for an extended period, indicating a failure to provide timely care. The CNA responsible admitted to not checking on the resident for over two hours, despite the care plan's instructions to provide care with each incontinent episode. The second resident's care plan included interventions for managing incontinence and preventing falls, which were not followed. The resident was found sitting on a saturated incontinence pad with a strong urine odor in the room, and a pool of urine was observed under the bed. The CNA confirmed that the resident had not been checked for over three hours, contrary to the care plan's requirement for regular checks and assistance. Both residents were cognitively intact, as indicated by their BIMS scores, and required assistance with personal hygiene and toileting, which was not adequately provided.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for two residents, leading to deficiencies in care. Resident #2 was observed on a bedside mat with a saturated incontinence brief that had sagged to his lower thighs. The Certified Nursing Assistant (CNA) responsible for his care admitted to not checking on him between 11:00 AM and 1:29 PM, despite care instructions requiring checks every two hours. Resident #2, who was admitted in March 2020, had a history of cerebral infarction, repeated falls, and malignant neoplasm of the bladder. His Minimum Data Set (MDS) indicated he required moderate assistance for toileting hygiene and was frequently incontinent. Similarly, Resident #3 was found with a soaked incontinence pad during care provided by another CNA. The CNA confirmed that the last check was conducted at 1:00 PM, with no care provided until 3:47 PM. Resident #3, admitted in November 2021, had diagnoses including Stage 3 Chronic Kidney Disease and Benign Prostatic Hyperplasia. His MDS indicated substantial assistance was needed for personal hygiene and supervision for toileting. Interviews with staff, including a Registered Nurse and the Director of Nursing, confirmed that CNAs were expected to make rounds every two hours to meet residents' needs, which was not adhered to in these cases.
Failure to Maintain Safe Mechanical Lift Operations
Penalty
Summary
The facility failed to maintain mechanical patient care equipment in a safe operational condition, specifically for one of the six mechanical lifts. During an observation, a stand-up lift on the 100 Hall was found to be non-functional when its hand control buttons were pressed. Attempts to resolve the issue by replacing the battery were unsuccessful until a third battery from another lift was used, leaving that lift inoperable. Further investigation revealed that the lift only operated when the battery was manually squeezed into place, indicating a mechanical issue with the battery connection. Interviews with staff, including LPNs, CNAs, and the Maintenance Director, revealed a lack of communication and reporting regarding the malfunctioning lift. The Maintenance Director had not received any work orders for the lift, and the issue was not documented in the facility's maintenance management software, TELS. The Director of Nursing confirmed that equipment in need of repair should be removed from use and documented, but this procedure was not followed. The resident involved in the incident had a history of cerebrovascular disease, repeated falls, and malignant neoplasm of the bladder, and was cognitively intact at the time of the deficiency.
Failure to Notify Physician of Severe Pain
Penalty
Summary
The facility failed to notify the physician of a resident's severe pain, which was initially rated at a 10 on a pain scale of 0-10, for one of the sampled residents. Upon admission, the resident reported severe pain in her right hip, but did not receive any pain medication until later in the evening, hours after her arrival. The facility's policy required the nurse to inform the physician of the availability of remote medications in the facility when there is a change in condition likely to require medication. However, the nurse on duty did not notify the resident's primary healthcare provider about the resident's pain. The resident was admitted with diagnoses including aftercare following joint replacement, pain in the right hip, and the presence of a right artificial hip joint. Despite the resident's report of severe pain upon arrival, the nurse confirmed that no pain medication was administered on the day of admission, and there was no documentation of any report of unrelieved pain to the primary healthcare provider. The Director of Nurses and the Administrator confirmed the lack of notification to the healthcare provider, which was a deviation from the facility's pain management policy.
Failure to Administer Timely Pain Management
Penalty
Summary
The facility failed to provide timely pain management for a resident who reported severe pain upon admission. The resident, who had undergone a right total hip arthroplasty, arrived at the facility with a pain level of 9 out of 10 and had a physician's prescription for Oxycodone-Acetaminophen. Despite this, the resident did not receive any pain medication until several hours after arrival, with the first dose administered at 8:35 PM, over five hours after admission. Interviews with staff revealed that the nursing staff was aware of the resident's pain issues prior to admission, as communicated during a nurse-to-nurse phone report. However, the Licensed Practical Nurse (LPN) on duty did not administer any pain medication during her shift and did not recall the resident's report of pain. The Registered Nurse (RN) Supervisor conducted a pain assessment but did not administer medication, as she was not the medication nurse. Additionally, the RN did not notify the resident's primary healthcare provider about the unrelieved pain, nor was there any documentation of such communication. The Director of Nurses (DON) confirmed that the facility had policies in place for pain management, including the use of an Emergency Drug Kit (EDK) and notifying the primary healthcare provider if pain was unrelieved. However, these procedures were not followed, as there was no documentation of pain management interventions from 3:00 PM to 8:35 PM. The facility's Administrator was unaware that the prescribed medication was not administered as ordered, and the resident's complaints of unrelieved pain were not reported to the primary healthcare provider.
Failure to Follow Dialysis Aftercare Orders
Penalty
Summary
The facility failed to follow physician orders and dialysis aftercare communication for a resident requiring dialysis services. The resident, who was cognitively intact and dependent on renal dialysis due to Type 2 Diabetes Mellitus with Diabetic Chronic Kidney, was observed with a pressure dressing on his right forearm AV shunt from the previous day's dialysis session. Despite clear instructions to remove the dressing within a specified timeframe, the facility staff did not adhere to these orders, leading to the resident returning from dialysis with the dressing still in place. Interviews with the dialysis unit Facility Administrator and the Nurse Practitioner revealed ongoing communication issues between the dialysis unit and the facility. The dialysis unit had repeatedly stressed the importance of removing the pressure dressing to prevent damage to the resident's new access, but the facility staff failed to comply. The Director of Nurses acknowledged the responsibility of RNs and LPNs to maintain AV shunts and admitted that the facility did not follow up on conflicting messages from the dialysis unit regarding dressing removal times, resulting in inadequate care for the resident's AV shunt.
Incorrect MDS Coding for Resident Discharge
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for one of the sampled residents, Resident #126. The resident was admitted with diagnoses of acute kidney failure and Type 2 Diabetes Mellitus. Upon discharge, the MDS was incorrectly coded as a discharge to a short-term general hospital, while the resident was actually discharged to home with medications and home health services, including physical, occupational, and speech therapy. This discrepancy was identified through a review of the facility's records and confirmed by interviews with the staff. The MDS Coordinator and the Director of Nursing (DON) both acknowledged the error, confirming that the resident was discharged to live with her sister, not to a hospital. The MDS was coded by an LPN, and the MDS Coordinator did not verify the accuracy of the coding. The Administrator also expected the MDS Coordinator to ensure the correctness of the coding. This oversight led to the incorrect documentation of the resident's discharge status, which was not aligned with the facility's policy of utilizing the most up-to-date Resident Assessment Instrument (RAI) manual for accurate coding.
Failure to Conduct PASRR Level II for Resident with Mental Disorder
Penalty
Summary
The facility failed to ensure a Pre-Admission Screening and Resident Review (PASRR) Level II was obtained for a resident diagnosed with a serious mental disorder. The resident, who was admitted to the facility with a diagnosis of Paranoid Schizophrenia, initially came for short-term therapy and was later transitioned to long-term care. The Pre-Admission Screening (PAS) was completed upon admission for short-term care, but the necessary PASRR Level II screening was not conducted when the resident's status changed to long-term care. Interviews with facility staff revealed a lack of awareness and oversight regarding the need for a PASRR Level II screening. The Assistant Business Office Manager acknowledged that the PAS should have been updated when the resident's care status changed. The Administrator also confirmed that she was unaware of the requirement for a Level II PASRR referral upon the resident's transition to long-term care. The resident was cognitively intact, as indicated by a Brief Interview of Mental Status (BIMS) score of 15, but there was no documentation of a referral for the necessary PASRR Level II screening.
Medication Error Rate Exceeds 5% Due to Improper Eye Drop Administration
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in an 8% error rate. This was identified during a medication administration observation where a registered nurse (RN) administered two different eye drops to a resident without waiting the required three to five minutes between applications. The facility's policy, revised in January 2014, clearly states that when administering two or more different eye drops, a waiting period of three to five minutes is necessary to prevent one drop from washing out the other. However, the RN only waited 20 seconds between administering Prednisolone Acetate Ophthalmic Suspension and Ofloxacin Ophthalmic Solution to the resident. The resident involved had been admitted to the facility with diagnoses including total retinal detachment of the left eye and the presence of an intraocular lens. The resident had active physician orders for both eye drops to be administered four times a day following eye surgery. Despite having attended an inservice on medication procedures and guidelines, the RN did not adhere to the facility's policy during the administration. Interviews with the RN, the facility pharmacist, and the Director of Nursing confirmed the error and the importance of adhering to the waiting period between administering different eye drops.
Improper Handling of Dirty Linen by CNA
Penalty
Summary
The facility failed to adhere to its infection prevention and control policy regarding the handling and transportation of dirty linen. During an observation, a Certified Nursing Assistant (CNA) was seen carrying dirty linen against her clothes while walking down the hallway, instead of placing it in a leak-proof bag or container as required by the facility's policy. This action was confirmed by the CNA, who acknowledged that she should have used a plastic bag to prevent potential infection spread, but was unable to find one at the time. The Director of Nursing (DON) confirmed that the CNA's actions were against the facility's infection control policy and could potentially lead to infections among residents and staff. The CNA had previously been trained in infection control, as evidenced by an orientation checklist and a completion certificate for an eLearning course on infection prevention in long-term care settings. Despite this training, the CNA did not follow the proper procedures, leading to the deficiency noted in the report.
Failure to Revise Care Plans for Residents
Penalty
Summary
The facility failed to revise the care plans for two residents, leading to deficiencies in their care. For Resident #80, the care plan did not include interventions for the removal of the dialysis pressure dressing, despite multiple communications from the dialysis unit emphasizing the importance of timely removal to prevent damage to the resident's new access. Observations and interviews revealed that the facility did not update the care plan to reflect these instructions until after the State Agency's entrance, indicating a lack of communication and documentation by the nursing staff. For Resident #105, the care plan inaccurately reflected that the resident was receiving continuous tube feedings, although the physician's order had changed to bolus feedings five times a day due to the resident's tendency to unhook the feeding, posing a high risk for aspiration. Despite daily meetings intended to ensure care plans are updated with new orders, the care plan nurse confirmed that the care plan was not revised to reflect the new feeding order, highlighting a failure in the facility's process for updating care plans with current medical orders.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
