Yazoo City Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Yazoo City, Mississippi.
- Location
- 925 Calhoun Avenue, Yazoo City, Mississippi 39194
- CMS Provider Number
- 255146
- Inspections on file
- 25
- Latest survey
- December 2, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Yazoo City Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with paraplegia and a spinal cord injury, who was dependent on staff for toileting, did not receive incontinence care as outlined in the care plan. Observation revealed the resident's brief was saturated and unchanged overnight, and staff confirmed the care plan was not followed.
A resident who was dependent on staff for toileting due to paraplegia did not receive timely incontinent care, resulting in a saturated brief and incontinence pad. The resident reported not being checked or changed during the night, and staff confirmed that care had not been provided as required by facility policy.
A resident with hemiplegia, hemiparesis, hypertension, and blindness experienced multiple falls, but the care plan was not updated with new preventative interventions after each incident. The care plan only included post-fall actions such as neuro checks and notifications, without revising strategies to prevent further falls, as confirmed by the ADON.
A resident with hemiplegia, hemiparesis, hypertension, and blindness experienced five falls, including one resulting in a laceration and hematoma requiring emergency care. Despite facility policy requiring care plan updates after each fall, no new interventions were implemented following any of the incidents, and staff confirmed that the care plan was not revised to address the repeated falls.
A CNA misappropriated money from a resident with quadriplegia by accepting funds through Cash App and unauthorized use of the resident's trust fund card for personal purchases. The resident, who was cognitively intact, noticed unauthorized transactions and provided evidence linking the CNA to the misappropriation. Facility staff confirmed that only Social Services or Activities should assist with resident shopping, and the resident was unaware of this policy.
A resident with moderate cognitive impairment and high risk for wandering left the facility unnoticed due to a malfunctioning wander guard bracelet. Staff failed to monitor the resident adequately, as the resident was not checked on for several hours. The facility's policy on wander management was not effectively implemented.
A facility failed to implement care plans for a resident on Enhanced Barrier Precautions (EBP) and two residents requiring assistance with activities of daily living (ADL). An LPN did not follow EBP protocol during wound care, and two residents were found with neglected personal hygiene, including long, dirty nails and facial hair, despite care plans outlining necessary interventions. Staff confirmed the care plans were not followed.
Two residents in an LTC facility were not provided with necessary grooming and personal hygiene services. One resident, with moderate cognitive impairment, had long, jagged nails and facial hair despite expressing a desire for grooming. Another resident, cognitively intact but with quadriplegia, had excessively long, dirty fingernails and had repeatedly requested nail care. The DON acknowledged the facility's failure to meet these residents' grooming needs.
A resident's dignity was compromised when their urinary catheter bag was left uncovered, contrary to facility policy. The resident, who was cognitively intact and had a history of malignant neoplasm of the uterus and type 2 diabetes, expressed discomfort with the visibility of the urine. Staff interviews confirmed that the facility typically used privacy bags, but the resident's bag, likely from the hospital, was not covered, highlighting a lapse in maintaining resident dignity.
A facility failed to ensure a call light was accessible for a resident who relied on it for assistance. The resident, who was cognitively intact and had multiple health conditions, reported that the call light was not within reach. Observations confirmed the call light cord was tangled and inaccessible. Both a CNA and an RN acknowledged the issue, and the DON confirmed the facility's failure to secure the call light within the resident's reach.
A facility failed to resolve grievances related to missing clothing items for four residents, as identified during interviews and record reviews. Despite ongoing complaints documented in Resident Council meetings, the issue remained unresolved. Staff interviews confirmed awareness of the problem, with suggestions that laundry backlogs and unlabeled clothes contributed to the issue. The Administrator admitted awareness and efforts to address the problem, but it persisted. All involved residents were cognitively intact.
A facility failed to ensure a resident's code status was accurately reflected in the physician orders, leading to a discrepancy between the advance directive and the physician's order. The advance directive indicated a DNR preference, while the physician's order listed the resident as a full code. Staff interviews confirmed reliance on electronic medical records for code status, and the lack of a policy to address such discrepancies contributed to the issue.
The facility failed to maintain a clean and homelike environment, as evidenced by unsanitary conditions in multiple resident rooms. Observations included persistent odors, fecal matter on surfaces, improperly hung curtains, and black substances on air conditioning units. Housekeeping and CNA staff demonstrated a lack of clarity and training regarding cleaning responsibilities, contributing to these deficiencies. Additionally, a ceiling leak from an air conditioning unit was not addressed, further compromising the environment.
A resident receiving anticoagulant medication for Peripheral Vascular Disease was not monitored for signs of bruising and bleeding, as required by the facility's policy. Staff interviews confirmed the absence of a monitoring tool on the resident's MAR, despite the importance of such monitoring. The DON acknowledged the deficiency in monitoring the resident's condition.
A medication cart was left unlocked and unattended by an LPN during medication administration, contrary to facility policy. The cart was outside a resident's room for about 15 minutes, with residents nearby, creating a risk for unauthorized access. Staff interviews confirmed the cart should have been locked unless the nurse was present.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a wound and urinary catheter. An LPN performed wound care without donning a gown, contrary to the facility's EBP policy. The resident's care plan required EBP due to a deep tissue injury and indwelling device. The LPN admitted to forgetting the protocol, and an RN confirmed the oversight. The resident had a history of malignant neoplasm, pressure-induced injury, and diabetes, and was cognitively intact.
A high-risk resident with a history of wandering and delusional behavior managed to disassemble his bedroom window and leave the facility undetected. Despite being identified as high-risk and having a wander guard, the facility's measures were insufficient, leading to the resident being found several miles away by law enforcement approximately 5.5 hours later.
The facility failed to transport a dialysis resident to a scheduled surgical procedure to ligate an AV fistula, resulting in the resident being admitted to the hospital with a bleeding aneurysm and requiring a blood transfusion. The incident was identified as Immediate Jeopardy and Substandard Quality of Care by the State Agency due to the facility's neglect in ensuring the resident attended the critical appointment.
A facility failed to revise the care plan for a severely cognitively impaired resident, leading to the resident's unsupervised exit and subsequent elopement. Despite a BIMS score indicating severe cognitive impairment, the care plan was not updated to reflect the need for supervision during leave of absence (LOA). The resident was found by police approximately eight-tenths of a mile from the facility after being away for 81 minutes.
A severely cognitively impaired resident eloped from the facility and was found 0.8 miles away after being unsupervised for 81 minutes. The facility lacked effective communication and policies to prevent such incidents.
Failure to Provide Incontinence Care per Care Plan
Penalty
Summary
The facility failed to provide incontinence care in accordance with the care plan for one resident who was dependent on staff for toileting due to paraplegia and a C5-C7 spinal cord injury. The resident's care plan specified total assistance from two staff members for toileting and incontinence care as needed, due to the resident's self-care performance deficit and risk for skin integrity impairment. Facility policy required that residents unable to perform activities of daily living independently receive appropriate support, including elimination and toileting, in accordance with their care plan. On observation, a CNA verified that the resident's incontinence pad and brief were saturated and showed a light brown ring of dried urine, indicating the resident had not been changed throughout the night. The CNA confirmed the resident had not been changed since the start of her shift. The DON acknowledged that the care plan was not followed, as the resident did not receive the required incontinence care overnight. The resident was cognitively intact and dependent on staff for toileting at the time of the deficiency.
Failure to Provide Timely Incontinent Care for Dependent Resident
Penalty
Summary
A deficiency occurred when a dependent resident did not receive timely assistance with activities of daily living, specifically incontinent care. The facility's policy requires that residents unable to perform ADLs independently receive necessary support, including toileting and elimination care. On the morning of the survey, the resident reported that a CNA did not check or change him during the night, and that staff would leave him wet if he was asleep. Observation confirmed that the resident's incontinence pad and brief were saturated with urine, with a visible light brown ring indicating prolonged exposure. The CNA assigned to the resident acknowledged that the resident had not been changed as required. Further interviews with the DON and ADON confirmed that residents should be checked and provided incontinent care at least every two hours, and agreed that the resident's condition indicated care had not been provided in a timely manner. The resident, who was admitted with paraplegia and assessed as cognitively intact but dependent with toileting, did not receive the necessary assistance as outlined in facility policy.
Failure to Update Care Plan with Preventative Interventions After Multiple Falls
Penalty
Summary
The facility failed to update and revise the care plan for a resident after multiple falls, as required by its own Fall Prevention Program policy. The policy specifies that all residents should be assessed for fall risk at admission, quarterly, and after any significant change in condition, with the care plan updated to reflect new risks and appropriate interventions. Despite the resident experiencing five separate falls, the care plan only documented post-fall actions such as neuro checks and notifications to responsible parties and medical staff, without adding or revising any preventative interventions to address the ongoing risk of falls. The resident involved had a history of hemiplegia and hemiparesis following cerebrovascular disease, hypertension, and blindness, and was admitted with these diagnoses. After one of the falls, the resident was found with a laceration and hematoma and required emergency room evaluation. During an interview, the ADON confirmed that no new interventions or care plan revisions were implemented following any of the falls, acknowledging that the care plan should have been updated with new fall prevention strategies after each incident.
Failure to Update Fall Prevention Interventions After Multiple Resident Falls
Penalty
Summary
The facility failed to implement effective supervision and accident prevention interventions for a resident with a documented history of falls and multiple risk factors, including hemiplegia, hemiparesis, hypertension, and blindness. Despite the facility's policy requiring fall risk assessments and updates to the care plan after each fall, the resident experienced five separate falls over a period of several months. After each incident, including one resulting in a laceration and hematoma to the left eyebrow that required emergency department treatment, no new interventions were documented or added to the resident's care plan. Interviews with staff confirmed that the resident's bed was positioned against the wall due to his fall history, but no additional measures were taken after repeated falls. Staff also noted that the resident sometimes pushed against the wall, which may have contributed to the bed shifting and a subsequent fall. The Assistant Director of Nursing acknowledged that the facility did not initiate new interventions following the repeated falls, despite the policy and the resident's ongoing incidents.
CNA Misappropriation of Resident Funds via Cash App and Trust Fund Card
Penalty
Summary
A Certified Nursing Assistant (CNA) misappropriated funds from a resident who was cognitively intact and diagnosed with quadriplegia. The resident began sending money to the CNA via Cash App to purchase food and paid additional fees for this service. In April, the resident provided her trust fund card to the CNA for continued shopping assistance. Over time, the resident noticed unauthorized charges on both her Cash App and trust fund accounts, including transactions that coincided with the CNA's personal activities, such as dining at a restaurant. The resident provided screenshots and account summaries showing numerous unauthorized transactions totaling thousands of dollars. Interviews with facility staff revealed that the standard practice was for Social Services or the Activity Director to shop for residents, and staff were not permitted to take resident debit cards or receive money via Cash App. The resident was unaware of this policy and did not request assistance from these departments. The CNA denied the unauthorized transactions, but evidence from account records and resident testimony identified the CNA as the recipient of the funds. The facility's policy prohibits the misappropriation of resident property or finances, but this policy was not followed in this case, resulting in significant financial loss for the resident.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision and monitoring for a resident identified as high risk for wandering. The resident, who has moderate cognitive impairment, was able to leave the facility without staff noticing for several hours. The resident's wander guard bracelet, which is supposed to alert staff if the resident attempts to leave, malfunctioned and did not trigger an alarm when the resident exited the building. This malfunction was sudden, and previous checks of the bracelet had not revealed any issues. Staff interviews revealed that the resident was last seen by an LPN around lunchtime and was not checked on again until late afternoon, despite being at high risk for wandering. The CNA on duty also confirmed that she did not attempt to locate the resident before her shift ended. The facility's policy on wander management and resident elopement was not effectively implemented, as staff did not monitor the resident frequently enough to prevent the elopement incident.
Failure to Implement Care Plans for EBP and ADL
Penalty
Summary
The facility failed to implement a care plan for Resident #20, who was on Enhanced Barrier Precautions (EBP) due to a deep tissue injury on the left heel and a urinary catheter. During an observation, an LPN performed wound care without donning a gown, which is a requirement under EBP to prevent the spread of infection. The LPN admitted to forgetting the protocol due to nervousness, and the RN confirmed the necessity of EBP for the resident's protection. Additionally, the facility did not follow the care plans for Residents #38 and #80 regarding activities of daily living (ADL). Resident #38, who had moderate cognitive impairment, was observed with long, jagged nails and facial hair, indicating neglect in personal hygiene care as outlined in her care plan. Similarly, Resident #80, who was cognitively intact but had left side hemiparesis, was found with excessively long and dirty fingernails, suggesting that the care plan for nail care was not implemented. Both residents' care plans included specific interventions for personal hygiene that were not followed, as confirmed by staff interviews.
Failure to Provide Necessary Grooming and Hygiene Services
Penalty
Summary
The facility failed to provide necessary grooming and personal hygiene services for two residents who were unable to self-perform activities of daily living (ADLs). Resident #38 was observed with long, jagged nails and facial hair, which she expressed a desire to have trimmed and shaved. Despite informing staff of her preferences, these grooming needs were not addressed. The Director of Nursing (DON) acknowledged the responsibility of the staff to ensure residents' grooming needs are met and confirmed the facility's failure to provide the desired ADL care for Resident #38, who has a moderate cognitive impairment. Similarly, Resident #80 was found with excessively long, jagged fingernails with a dark brown substance underneath. He expressed a desire to have his nails cut and cleaned, having asked staff multiple times without success. The LPN and Infection Control Nurse confirmed the potential risk of self-injury and infection due to the untrimmed nails. The DON acknowledged Resident #80's request for nail care, and the facility's records showed no documentation of care refusals. Resident #80 is cognitively intact and requires assistance with personal hygiene due to quadriplegia.
Failure to Cover Urinary Catheter Bag Compromises Resident Dignity
Penalty
Summary
The facility failed to provide a resident with a dignified existence by not covering a urinary catheter bag, as required by their policy. The policy, titled 'Protocol for Keeping Catheter Bags Covered for Dignity Purposes in a Nursing Home,' mandates that catheter bags should be covered with an appropriate, discreet cloth or garment to maintain the dignity, privacy, and comfort of residents. However, observations revealed that Resident #20's catheter bag was left uncovered on multiple occasions, making the urine visible. This was confirmed during an interview with the resident, who expressed discomfort and a desire for the bag to be covered. Further investigation showed that Resident #20 had an order effective from 10/31/24 for a privacy bag or covering over the urine collection bag for dignity. Interviews with LPN #4 and RN #2 confirmed that the facility typically used blue privacy urinary bags for residents with catheters, but Resident #20's bag, which was uncovered, likely came from the hospital. Both staff members acknowledged the dignity issue and agreed that the situation should have been addressed. Resident #20, who was cognitively intact with a BIMS score of 14, had been admitted with diagnoses including Malignant Neoplasm of the Uterus and Type 2 Diabetes Mellitus.
Inaccessible Call Light for Cognitively Intact Resident
Penalty
Summary
The facility failed to ensure that a call light device was accessible for a dependent resident, identified as Resident #7. During an observation and interview, the resident stated that he used the call light to receive assistance for his care, but it was not within his reach. The call light cord was found twisted around the bed frame under the foot of the resident's bed, making the call light button inaccessible. A Certified Nursing Assistant (CNA) confirmed that the call light was not where the resident could reach it and proceeded to untangle the cord. A Registered Nurse (RN) also confirmed the inaccessibility of the call light and acknowledged that it should have been secured within the resident's reach. Resident #7 was admitted to the facility with diagnoses including Type 2 Diabetes Mellitus, Hypertensive Heart Disease with heart failure, Chronic Obstructive Pulmonary Disease, and a history of repeated falls. The resident was cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 14. The Director of Nursing (DON) confirmed that staff members were responsible for ensuring the call light was clipped to the bedding within the resident's reach, acknowledging the facility's failure to do so in this instance.
Unresolved Grievances Over Missing Clothes in LTC Facility
Penalty
Summary
The facility failed to resolve grievances related to missing clothing items for four residents, as identified during resident and staff interviews, record reviews, and facility policy reviews. The facility's policy on filing grievances and complaints, revised in June 2024, states that all grievances or recommendations from resident or family groups concerning issues of resident care will be considered and responded to in writing if requested. However, the Resident Council minutes revealed ongoing complaints about missing clothes on multiple occasions, including meetings held in May, June, August, September, and November 2024. Interviews with residents during a Resident Council meeting in November 2024 confirmed that the issue of missing clothes had been a persistent problem, with residents expressing concerns about missing items such as compression socks, jogging suits, and new ankle socks. Interviews with facility staff, including the Activity Director, Housekeeper/Laundry staff, and the Licensed Social Worker (LSW), confirmed that the issue of missing clothes had been ongoing and unresolved. The Activity Director stated that she notified the LSW and laundry staff about the issue after each Resident Council meeting, but the problem persisted. The Housekeeper/Laundry staff suggested that the issue might be due to laundry backlogs and clothes not being labeled with residents' names. The Administrator acknowledged awareness of the problem and admitted that efforts had been made to address it, but it remained unresolved. All four residents involved were cognitively intact, as indicated by their Minimum Data Set (MDS) assessments, with scores reflecting their cognitive status.
Discrepancy in Resident's Code Status Documentation
Penalty
Summary
The facility failed to ensure the accuracy of a resident's code status in the physician orders, which led to a discrepancy between the resident's advance directive and the physician's order. Specifically, the advance directive signed by the resident's family member indicated a preference to decline CPR, while the physician's order listed the resident as a full code, meaning CPR would be performed. This inconsistency was identified during a review of the resident's records and confirmed through staff interviews. Interviews with facility staff, including a registered nurse and the admissions coordinator, revealed that in the event of an emergency, staff would rely on the electronic medical record to determine the resident's code status. The admissions coordinator confirmed that the resident's family had elected for a DNR status, and the social services staff acknowledged the potential for the resident to be resuscitated against their wishes due to the mismatch in documentation. The facility did not have a policy in place to address discrepancies between advance directives and physician orders, contributing to the deficiency.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations of unsanitary conditions in resident rooms. On two separate survey days, surveyors noted a persistent smell of urine and the presence of a dark brown substance, suspected to be feces, in room [ROOM NUMBER]-P. Despite cleaning efforts by housekeeping staff, the substance remained on the bathroom floor, commode, and recliner. Interviews with housekeeping staff and CNAs revealed a lack of clarity and training regarding responsibilities for cleaning bodily fluids, contributing to the unsanitary conditions. In another room, [ROOM NUMBER], surveyors observed a large dried brown substance on the toilet bowl and a dark brown substance on the floor under the bed. The privacy curtain was improperly hung, and a black substance was noted around the door frame. Housekeeping staff confirmed these observations and acknowledged the need for thorough cleaning, indicating that the room had not been adequately maintained. Additionally, room [ROOM NUMBER]-W had an air conditioner unit with a black substance on the vents and control panel, which was confirmed by the RN Supervisor to be potentially harmful if inhaled. The facility's housekeeping practices, including deep cleaning schedules, were insufficient to address these issues. Furthermore, a large brown discolored area on the ceiling tiles at the end of the 200 hall was identified as a leak from an air conditioning unit, which had not been addressed by maintenance staff, further compromising the facility's environment.
Failure to Monitor Anticoagulant Therapy in Resident
Penalty
Summary
The facility failed to monitor a resident receiving anticoagulant medication for signs of bruising and bleeding, which is a requirement to ensure each resident's drug regimen is free from unnecessary drugs. The facility's policy titled Anticoagulation-Clinical Protocol, revised in November 2018, mandates monitoring for possible complications in individuals on anticoagulation therapy. However, a review of Resident #47's records revealed that there was no monitoring tool in place for staff to observe signs of bruising and bleeding associated with the anticoagulant medication Apixaban, prescribed for Peripheral Vascular Disease. Interviews with staff confirmed the deficiency. An LPN acknowledged that Resident #47 was on an anticoagulant and confirmed the absence of a monitoring task on the resident's MAR for bruising or signs of bleeding. The DON also confirmed that the resident was not being adequately monitored for potential outcomes associated with anticoagulation medications, despite the necessity of such monitoring. Resident #47 was admitted with medical diagnoses including Peripheral Vascular Disease, highlighting the importance of monitoring due to the prescribed anticoagulant therapy.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure the proper storage of drugs as evidenced by a medication cart being left unlocked during medication administration. An observation revealed that an LPN left the medication cart outside a resident's room with the medication drawers facing outward. The cart was unattended and unlocked for approximately 15 minutes while the LPN was inside the room administering medications. During this time, a resident was sitting beside the cart in a wheelchair, and two other residents self-propelled themselves by the cart, creating a potential risk for unauthorized access to medications. Interviews with facility staff confirmed the deficiency. The LPN acknowledged that the medication cart was supposed to be locked at all times unless the nurse was present and preparing medications for administration. An RN further confirmed that the medication carts should be locked to prevent unauthorized access when unattended. The RN stated that the only time the cart should be unlocked is when the nurse is actively retrieving medications. This incident highlights a breach in the facility's policy regarding the secure storage of medications.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident who required them due to having a wound and an indwelling medical device. During an observation, a Licensed Practical Nurse (LPN) performed wound care on the resident's left heel without donning a gown, which is a requirement under the facility's EBP policy. The LPN acknowledged knowing the EBP protocol but admitted to forgetting to wear the gown due to nervousness. The purpose of EBP, as stated by the LPN, is to prevent the spread of infection and protect both residents and staff. The resident in question had a urinary catheter and a deep tissue injury on the left heel, necessitating the use of EBP. The resident's care plan explicitly stated the need for EBP during wound care. The Registered Nurse (RN) confirmed that the LPN should have worn gloves and a gown while providing care. The resident's medical history included a malignant neoplasm of the uterus, pressure-induced deep tissue damage of the left heel, and type 2 diabetes mellitus. The resident was cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 14.
Failure to Prevent Elopement of High-Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a delusional resident identified as high risk for elopement. The resident, who had a history of wandering and was cognitively intact but delusional, managed to disassemble his bedroom window and leave the facility undetected. He was found several miles away by local law enforcement approximately 5.5 hours after he was last seen by a Certified Nursing Assistant (CNA). The resident had previously attempted to leave the facility and had been given a wander guard, which he removed before exiting through the window. Interviews with staff revealed that the resident had voiced delusional statements about needing to leave for a job and had previously attempted to leave the facility through the front door. Despite being identified as a high-risk wanderer and having a wander guard, the facility's measures were insufficient to prevent his elopement. The resident's care plan had been updated multiple times to reflect his high risk for elopement, but these measures did not prevent the incident. The facility's failure to provide adequate supervision and secure the resident's environment led to the resident's unsupervised and unwitnessed departure. The resident was found safe but delusional and was placed on one-to-one observation upon his return. The facility's policies and procedures for monitoring high-risk residents were found to be inadequate, leading to the identification of Immediate Jeopardy and Substandard Quality of Care by the State Agency.
Removal Plan
- LPN #1 made rounds and Resident #1 was not present in his room and his window was disassembled.
- LPN #1 initiated a facility elopement drill. Resident #1 was not located in the facility and all residents were accounted for.
- The Administrator was notified by LPN #1 of Resident #1 missing from facility.
- The Director of Nurses was notified by the Administrator of Resident #1 missing from the facility.
- The local Police Department was notified by RN Supervisor #1 of Resident #1 missing from the facility.
- The facility Administrator was notified by the Sheriff Department that Resident #1 had been located.
- The Administrator and Director of Nurses picked up Resident #1 at local dispatch office.
- The RN Supervisor #1 conducted a head-to-toe body assessment on Resident #1 to review for any skin abnormalities or concerns. Resident #1 had no negative skin issues or concerns.
- The DON oversaw verification of all residents in facility using census. The census in the facility was 149 with 2 residents in the hospital. All 149 residents were accounted for or verified.
- Resident #1 was placed on 1:1 monitoring.
- The wander guard bracelet was verified to work properly by checking function with door alarm by DON, and then placed on Resident #1's left wrist.
- The facility staff was interviewed by the Administrator to determine the timeline of events leading up to Resident #1's exit of facility. Statements were collected.
- Staff present in the facility during the time of Resident #1 exit, received immediate in-service by the DON and Administrator on the Elopement procedures, Abuse/Neglect, Vulnerable Adult Act and Rounding.
- All required state agencies were notified of Resident #1 elopement.
- Maintenance assessed Resident #1's window. Window glass appeared intact and window stopper in place. Maintenance reassembled window and inserted additional safety mechanisms to prevent window from being disassembled in the future by Resident #1.
- The LPN #1 initiated facility-based incident reporting on Resident #1.
- Maintenance initiated an audit of all 1st floor windows to ensure they are intact and functioning properly. All windows were intact and functioning properly. Maintenance initiated adding additional safety mechanisms to prevent window from being disassemble from frame.
- The Nurse Practitioner was notified by the RN Supervisor #1 of Resident #1 elopement and return to the facility.
- Resident #1 Responsible Party was notified by the Administrator that Resident #1 had been returned to the facility.
- Licensed nurses were notified to perform acute charting on Resident #1 every shift for the next 72 hours to review resident's physical, mental, and psychosocial needs.
- The DON completed a post Elopement incident. Resident #1 remains high risk for Elopement.
- The Social Services Director followed up on resident's psychosocial needs and will continue for the next 72 hours.
- The Social Services Director reviewed the wander and elopement binders to ensure all are reflective of results.
- Resident #1 was assessed by Psychiatric NP.
- A Quality Assurance Committee Meeting was held with the Medical Director, Administrator, Assistant Administrator, Director of Nursing/Infection Preventionist, and the Assistant Director of Nursing to discuss Resident #1 elopement along with plan of correction.
- The Assistant Director of Nursing audited current high-risk wander patients to review orders and care plans for accuracy. There are currently six wander patients.
- The RN Supervisor #2 performed an elopement drill to review and educate night shift on policies and procedures on elopement.
- The RN Supervisor #1 performed an elopement drill to review and educate evening shift on policies and procedures on elopement.
Failure to Transport Resident for Critical Surgery
Penalty
Summary
The facility failed to ensure the right to be free from neglect when it did not transport a dialysis resident to a scheduled surgical procedure to ligate an arteriovenous (AV) fistula. This failure resulted in the resident being admitted to the hospital with a bleeding aneurysm of the AV fistula, requiring a blood transfusion of four units of blood. The incident was identified as Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) by the State Agency (SA), which began when the facility neglected to transport the resident to the appointment, placing the resident and others in a situation likely to cause serious harm or death. The facility's policy on abuse prohibition, revised in November 2023, was intended to prevent neglect, but the facility had no specific policy related to appointments. The resident's medical records indicated that the dialysis clinic had communicated the importance of the surgical procedure scheduled for March 21, 2024, to the facility. However, the facility staff failed to follow up on the appointment time, leading to the resident missing the surgery. The resident subsequently experienced severe bleeding from the AV fistula site and was admitted to the hospital with acute blood loss anemia. Interviews with facility staff revealed a breakdown in communication and follow-up regarding the resident's appointments. The agency LPN handed over the appointment information to the charge nurse, who then passed it to the Appointment Scheduler. Despite multiple confirmations from the dialysis clinic about the critical nature of the appointments, the facility staff did not ensure the resident was transported for the surgery. This failure in communication and follow-up led to the resident's hospitalization and the identification of Immediate Jeopardy by the State Agency.
Removal Plan
- The Interim DON contacted Resident #2 general surgeon office to confirm phone for communication that is currently in their file and provide the facility contact information for any further communication.
- Resident Council Meeting was held with the Activity Director, Assistant Activity Director #1, Assistant Activity Director #2, and Resident Council President, and eighty-two (82) total resident presents to inform them the facility received Immediate Jeopardies.
- The Staff Development initiated in-servicing with all licensed nurses, transportation, front desk receptionist on communication with appointments to include the process with signing resident in and out of facility, the daily transportation log along with the sign out binder. Inservice also includes adding a step to the appointment communication process with Admission Coordinator to review the communication tab within the electronic records to ensure all appointments are listed. No staff will be allowed to return to work without completing.
- The Administrator held a one-to-one in-service with Admission Coordinator on the appointment scheduling process to include communication, scheduling and following up on appointments.
- The Admission Coordinator conducted an audit of current dialysis patients to review for appointments by contacting the dialysis center and verifying any outside appointment to ensure facility followed up correctly. There are currently twelve (12) dialysis patients. All appointments were followed up.
- Medical Director, Administrator, Assistant Administrator, Interim Director of Nursing/ Infection Preventionist, and Assistant Director of Nursing held a Quality Assurance Performance Improvement Meeting to include notification of Immediate Jeopardy to review steps initiated to prevent any further reoccurrence to include audits on elopements, care plans, orientation binder, in-services on appointment process, audits of dialysis residents and contacting dialysis to verify appointments.
- The Assistant Administrator conducted a one-to-one in-service with Front Desk Receptionist to discuss appointment log, resident leave of absence binder, and how to locate current BIMS for residents.
Failure to Revise Care Plan Leads to Resident Elopement
Penalty
Summary
The facility failed to revise the care plan for a severely cognitively impaired resident who eloped from the facility. The resident, who had a history of epilepsy and dependence on a wheelchair, was found approximately eight-tenths of a mile from the facility by police after being away for 81 minutes. The resident's care plan, last revised on 11/02/23, did not reflect his inability to go on leave of absence (LOA) unsupervised despite a Brief Interview for Mental Status (BIMS) score of 5, indicating severe cognitive impairment. Staff interviews confirmed that the resident was no longer allowed to go out unsupervised due to his confusion, but this change was not updated in the care plan until after the elopement incident on 3/31/24. On the day of the incident, an agency LPN opened the door for the resident, mistakenly believing he was going to sit on the front porch. The resident exited the facility at 7:25 PM and was later found by police. The facility's Director of Nursing (DON) and Administrator were notified, and the resident was picked up and returned to the facility. Upon return, the resident was assessed with no injuries noted, and a wander guard bracelet was placed on his wrist. However, the failure to update the care plan in a timely manner directly contributed to the resident's unsupervised exit. Interviews with the Assistant Director of Nursing (ADON) and the Social Worker (SW) confirmed that the resident's BIMS score had been below 12 since 2/22/24, indicating severe cognitive impairment. Despite this, the care plan was not updated to reflect the resident's need for supervision during LOA. The SW acknowledged that the care plan should have been revised when the resident's BIMS score fell below 12, but it was not updated until after the elopement incident. The Interim DON also agreed that the care plan should have been updated at the time the resident was determined to be unsafe to go LOA unsupervised.
Removal Plan
- The interim Director of Nursing (DON) and Licensed Practical Nurse (LPN) #1 conducted a head-to-toe body assessment on Resident #1 to review for any skin abnormalities or concerns. Resident #1 had no negative skin issues or concerns.
- The Interim DON oversaw verification of all residents in facility using census with only one resident out of the facility and currently in the hospital. The census in the facility was 140.
- Staff present in the facility during the time of Resident #1 exit received immediate in-service by the Interim DON and Administrator on the procedures with residents signing out to exit facility to include verification of BIMS (Brief Interview for Mental Status).
- The Interim DON and Administrator initiated servicing with all staff present on Abuse, Neglect, Resident Rights, Vulnerable Adult, and Wandering. Staff Development will continue In-Servicing. No staff will be allowed to return to work without completing.
- Resident #1 wandering evaluation was reviewed by Interim Director of Nursing and indicated low risk for wandering. Resident #1 wandering evaluation was updated by the Interim DON and Administrator.
- The wander guard bracelet was verified to work properly by checking function with door alarm by Administrator, and then placed on Resident #1's left wrist.
- The facility camera was reviewed by the Administrator to determine the timeline of events leading up to Resident #1 exit of facility.
- The Administrator interviewed staff present of Resident #1 leaving the facility unattended. The agency LPN who held the door open stated that she was not aware he could not leave the facility.
- The Mississippi State Department of Health was notified of Resident #1 elopement.
- The Nurse Practitioner (NP) was notified by the Administrator of Resident #1 elopement and return to facility.
- Licensed nurses were notified to perform acute charting on Resident #1 every shift for the next 72 hours to review resident's physical, mental, and psychosocial needs.
- The LPN #1 initiated facility-based incident reporting on Resident #1.
- The Corporate Clinical Specialist (CCS) initiated an audit of the wander risk evaluations on all 140 active residents. Results indicated twelve (12) residents requiring updates to the wander system. All updates were corrected.
- The Social Services Director updated the wander and elopement binders to ensure all are reflective of results.
- The Maintenance Supervisor checked all wander guards to verify all were in correct working order with no issues found.
- The NP placed orders for Resident to obtain Urinalysis, Comprehensive Metabolic Panel, and Complete Blood Count.
- The Administrator performed an elopement drill to review and educate day shift on policies and procedures on elopement.
- Social Services completed a BIMS on Resident #1 which resulted in moderate cognitive impairment of a 9.
- A Quality Assurance Committee Meeting was held with the Medical Director, Administrator, Assistant Administrator, Interim Director of Nursing/Infection Preventionist, and the Assistant Director of Nursing to discuss Resident #1 elopement along with plan of correction.
- Resident #1 was assessed by the NP no issues found and care plan was updated by interdisciplinary team to reflect changes in leave of absence status.
- The Registered Nurse Supervisor #1 performed an elopement drill to review and educate night shift on policies and procedures on elopement.
- The Interim DON and Administrator Assistant performed an elopement Drill and educated staff on day shift.
- The Administrator Assistant developed an orientation binder for all agency staff onboard to be in-serviced on facilities policies and procedures to include wandering, elopement, where to find if a resident is allowed to out leave of absence, and appointment guidelines.
- NP reviewed results of labs ordered and placed an order for Levaquin 750 milligrams one by mouth at bedtime for 7 days related to Urinary Tract Infection to start.
- A current BIMS list will be in the leave of absence binder updated weekly or as needed by Social Services. All residents with BIMS under 12 will not be allowed to leave the facility without supervision.
- The final letter of investigation was sent to the Mississippi State Department of Health.
- The Attorney General was notified regarding the results of the Investigation.
- The Administrator performed an elopement drill to review and educate evening shift on policies and procedures on elopement.
- The Interim DON contacted Resident #2 general surgeon office to confirm phone for communication that is currently in their file and provide the facility contact information for any further communication.
- Resident Council Meeting was held with the Activity Director, Assistant Activity Director #1, Assistant Activity Director #2, and Resident Council President, and eighty-two (82) total resident presents to inform them the facility IJs.
- An in-service was initiated by Staff Development Coordinator on leave of absence process and how to locate residents BIMS. No staff will be allowed to return to work without signing.
- The Administrator held a one-to-one in-service with the Licensed Social Worker on Leave of Absences Care plans to include who can exit facility, supervision needed and process for a change in BIMS (Brief Interview for Mental Status).
- Medical Director, Administrator, Assistant Administrator, Interim Director of Nursing/ Infection Preventionist, and Assistant Director of Nursing held a Quality Assurance Performance Improvement Meeting to include notification of Immediate Jeopardy to review steps initiated to prevent any further reoccurrence to include audits on elopements, care plans, orientation binder, in-services on appointment process, audits of dialysis residents and contacting dialysis to verify appointments.
- Regional Case Mix conducted in-service with Minimum Data Set (MDS) to include implementation, Reviewing, Revising, and Resolving person-centered care plans.
- An audit was initiated by Social Services Director on leave of absence care plans to ensure resident with impaired cognition receive adequate supervision.
- The Assistant Administrator conducted a one-to-one in-service with Front Desk Receptionist to discuss appointment log, resident leave of absence binder, and how to locate current BIMS for residents.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a severely cognitively impaired resident. The resident, who had a Brief Interview for Mental Status (BIMS) score of 5 indicating severe cognitive impairment, was last observed in the facility at 7:25 PM. The resident was able to leave the facility unsupervised and was found approximately 0.8 miles away in the community at 8:41 PM. The resident was outside for approximately 81 minutes before being located by the police and returned to the facility. Interviews with staff revealed that there was no effective communication system in place to inform staff which residents were not allowed to leave the facility unsupervised. The agency nurse who let the resident out was unaware that the resident could not leave the facility alone. Additionally, the facility did not have a policy related to resident leave of absence, and the existing Wanderer Management, Monitoring System & Resident Elopement Protocol was not effectively implemented. The facility's failure to provide adequate supervision and effective communication resulted in the resident's elopement, posing a risk of serious harm, injury, or death.
Removal Plan
- The interim Director of Nursing (DON) and Licensed Practical Nurse (LPN) #1 conducted a head-to-toe body assessment on Resident #1 to review for any skin abnormalities or concerns. Resident #1 had no negative skin issues or concerns.
- The Interim DON oversaw verification of all residents in facility using census with only one resident out of the facility and currently in the hospital. The census in the facility was 140.
- Staff present in the facility during the time of Resident #1 exit received immediate in-service by the Interim DON and Administrator on the procedures with residents signing out to exit facility to include verification of BIMS (Brief Interview for Mental Status).
- The Interim DON and Administrator initiated servicing with all staff present on Abuse, Neglect, Resident Rights, Vulnerable Adult, and Wandering. Staff Development will continue In-Servicing. No staff will be allowed to return to work without completing.
- Resident #1 wandering evaluation was reviewed by Interim Director of Nursing and indicated low risk for wandering. Resident #1 wandering evaluation was updated by the Interim DON and Administrator.
- The wander guard bracelet was verified to work properly by checking function with door alarm by Administrator, and then placed on Resident #1's left wrist.
- The facility camera was reviewed by the Administrator to determine the timeline of events leading up to Resident #1 exit of facility.
- The Administrator interviewed staff present of Resident #1 leaving the facility unattended. The agency LPN who held the door open stated that she was not aware he could not leave the facility.
- The Mississippi State Department of Health was notified of Resident #1 elopement.
- The Nurse Practitioner (NP) was notified by the Administrator of Resident #1 elopement and return to facility.
- Licensed nurses were notified to perform acute charting on Resident #1 every shift for the next 72 hours to review resident's physical, mental, and psychosocial needs.
- LPN #1 initiated facility-based incident reporting on Resident #1.
- The Corporate Clinical Specialist (CCS) initiated an audit of the wander risk evaluations on all 140 active residents. Results indicated twelve (12) residents requiring updates to the wander system. All updates were corrected.
- The Social Services Director updated the wander and elopement binders to ensure all are reflective of results.
- The Maintenance Supervisor checked all wander guards to verify all were in correct working order with no issues found.
- The NP placed orders for Resident to obtain Urinalysis, Comprehensive Metabolic Panel, and Complete Blood Count.
- The Administrator performed an elopement drill to review and educate day shift on policies and procedures on elopement.
- Social Services completed a BIMS on Resident #1 which resulted in moderate cognitive impairment of a 9.
- A Quality Assurance Committee Meeting was held with the Medical Director, Administrator, Assistant Administrator, Interim Director of Nursing/Infection Preventionist, and the Assistant Director of Nursing to discuss Resident #1 elopement along with plan of correction.
- Resident #1 was assessed by the NP no issues found and care plan was updated by interdisciplinary team to reflect changes in leave of absence status.
- The Registered Nurse Supervisor #1 performed an elopement drill to review and educate night shift on policies and procedures on elopement.
- The Interim DON and Administrator Assistant performed an elopement Drill and educated staff on day shift.
- The Administrator Assistant developed an orientation binder for all agency staff onboard to be in-serviced on facility's policies and procedures to include wandering, elopement, where to find if a resident is allowed to out leave of absence, and appointment guidelines.
- NP reviewed results of labs ordered and placed an order for Levaquin 750 milligrams one by mouth at bedtime for 7 days related to Urinary Tract Infection to start.
- A current BIMS list will be in the leave of absence binder updated weekly or as needed by Social Services. All residents with BIMS under 12 will not be allowed to leave the facility without supervision.
- The final letter of investigation was sent to the Mississippi State Department of Health.
- The Attorney General was notified regarding the results of the Investigation.
- The Administrator performed an elopement drill to review and educate evening shift on policies and procedures on elopement.
- The Interim DON contacted Resident #2 general surgeon office to confirm phone for communication that is currently in their file and provide the facility contact information for any further communication.
- Resident Council Meeting was held with the Activity Director, Assistant Activity Director #1, Assistant Activity Director #2, and Resident Council President, and eighty-two (82) total resident presents to inform them the facility received Immediate Jeopardies.
- An in-service was initiated by Staff Development Coordinator on leave of absence process and how to locate residents BIMS. No staff will be allowed to return to work without signing.
- The Administrator held a one-to-one in-service with the Licensed Social Worker on Leave of Absences Care plans to include who can exit facility, supervision needed and process for a change in BIMS (Brief Interview for Mental Status).
- Medical Director, Administrator, Assistant Administrator, Interim Director of Nursing/ Infection Preventionist, and Assistant Director of Nursing held a Quality Assurance Performance Improvement Meeting to include notification of Immediate Jeopardy to review steps initiated to prevent any further reoccurrence to include audits on elopements, care plans, orientation binder, in-services on appointment process, audits of dialysis residents and contacting dialysis to verify appointments.
- Regional Case Mix conducted in-service with Minimum Data Set (MDS) to include implementation, Reviewing, Revising, and Resolving person-centered care plans.
- An audit was initiated by Social Services Director on leave of absence care plans to ensure resident with impaired cognition receive adequate supervision.
- The Assistant Administrator conducted a one-to-one in-service with Front Desk Receptionist to discuss appointment log, resident leave of absence binder, and how to locate current BIMS for residents.
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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