Azalea Health Center By Harborview
Inspection history, citations, penalties and survey trends for this long-term care facility in Augusta, Georgia.
- Location
- 1600 Anthony Road, Augusta, Georgia 30904
- CMS Provider Number
- 115044
- Inspections on file
- 17
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Azalea Health Center By Harborview during CMS and state inspections, most recent first.
Surveyors observed an unattended, unlocked medication cart with a medication bottle and a cup containing two loose pills left on top, with no nursing staff nearby, contrary to facility policy requiring medications to be under direct observation or locked during a med pass. An LPN reported leaving the medications on the cart while taking a resident to their room to check insulin, and both the DON and the Administrator confirmed that medications should not be left unattended and that once medications are removed, they are expected to be administered immediately.
The facility did not maintain the required eight consecutive hours of RN coverage each day, as evidenced by multiple days without an RN on duty. Both the staffing scheduler and DON were unaware of the specific requirements for RN coverage and were uncertain about whether the DON could be counted toward these hours.
Staff did not adhere to hand hygiene protocols during medication administration and resident care, with LPNs failing to perform hand hygiene between residents and CNAs not following Enhanced Barrier Precautions, including not wearing gowns or performing hand hygiene when assisting a resident with incontinence and pressure ulcers.
The facility failed to submit PASRR Level II for four residents after new mental illness diagnoses were added, as required by policy. Residents with diagnoses such as depression, PTSD, and bipolar disorder did not receive the necessary Level II reviews, despite exhibiting behavioral symptoms. The oversight was confirmed by facility staff, including the Regional Nurse Consultant and the new Social Services Director, who was unaware of the residents' PASRR status.
The facility failed to provide adequate ADL care for three residents, leading to unmet needs and diminished quality of life. A resident with severe cognitive impairment had not received a shower in a month due to transport issues, while another with moderate impairment was observed with unkempt hair and dirty fingernails. A third resident, requiring moderate assistance, reported not being offered showering help, with observations confirming the lack of hygiene care.
A facility failed to maintain a medication error rate below five percent, resulting in a 37.04 percent error rate for a resident. Medications scheduled for 9:00 am were administered late at 10:43 am, and one medication was unavailable. The DON and RN confirmed the deviation from the facility's policy, which requires medications to be given within one hour of the scheduled time.
The facility failed to maintain a clean, homelike, and safe environment in one of its units, with observations revealing cluttered living areas, exposed sheet rock, chipped sink ledges, and hard-to-open bathroom doors. Privacy curtains had brown spots, and walls had black marks and peeling wallpaper. The laundry room had missing and water-stained ceiling tiles, and a ventilation unit was improperly wrapped. These conditions were confirmed by the Administrator and Environmental Services Manager.
A facility failed to protect residents' medications from misappropriation during administration. An RN, unable to find a resident's prescribed metoprolol ER 50 mg, obtained two 25 mg tablets from another nurse, who took them from a different resident's supply. The DON confirmed that the correct procedure was not followed, breaching the facility's medication administration policy.
A resident with hypertension did not receive timely medication due to unavailability in the medication cart and lack of a backup pharmacy provider. The facility's policy on timely medication acquisition was not followed, and the DON confirmed awareness of the issue with medication reordering.
A resident with hypertension did not receive their prescribed diltiazem ER 120 mg at the scheduled time due to unavailability. The medication, which should have been administered within one hour of the 9:00 am schedule, was given after 4:00 pm. This delay was confirmed by the RN, LPN, and DON, who acknowledged the medication was not available and administered outside the required timeframe.
Unattended and Unsecured Medication Cart with Accessible Medications
Penalty
Summary
Surveyors identified a deficiency related to medication security when one of three medication carts was found unattended and unlocked, with a medication bottle and a medication cup containing two loose pills left on top of the cart. The facility’s Medication Storage policy, revised on 03/01/2025, requires that during a medication pass, medications must be under the direct observation of the person administering them or locked in the medication storage area or cart. During an observation on 04/20/2026 at 2:27 PM, there was no nursing staff in proximity to the cart or in the hallway while the medications remained accessible. In an interview at the same time, an LPN stated that medications should not be left out on the medication cart and explained that he had taken the resident back to the room to check insulin, leaving the medications on the cart. In separate interviews, the DON and the Administrator both confirmed that medications should not be left unattended on the medication cart and that the expectation is that once medications are taken out, they should be given to the resident, indicating that the observed practice did not meet the facility’s standard of practice. The deficient practice had the potential to allow residents and/or visitors unauthorized access to medications, as documented in the report.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for at least eight consecutive hours each day, as required. Review of staffing schedules and time punch cards revealed that there was no RN coverage on six specific days, despite a census of 87 residents. The job description for RNs indicated their role in providing skilled nursing care under physician direction. Interviews with the staffing scheduler and the Director of Nursing (DON) revealed a lack of awareness regarding the requirement for daily RN coverage, with both staff members expressing uncertainty about whether the DON could be counted toward the required RN hours and whether the facility census affected this requirement. The DON confirmed that on days with no RN listed on the schedule or time punch card, there was no RN on shift.
Failure to Follow Hand Hygiene and Enhanced Barrier Precautions During Resident Care
Penalty
Summary
Staff failed to comply with established infection prevention and control protocols, specifically regarding hand hygiene and Enhanced Barrier Precautions (EBP). During medication administration, two LPNs were observed not performing hand hygiene between residents, despite facility policy requiring hand hygiene before and after glove use, between resident contacts, and before handling medications. Both LPNs acknowledged not following the required hand hygiene procedures during their medication passes. Additionally, two CNAs were observed providing care to a resident in a room marked for EBP without performing hand hygiene before donning or after removing gloves, and without wearing the required gown. The CNAs assisted a resident who was incontinent and had pressure ulcers, and they were unaware of the EBP signage on the room door. Both confirmed they did not follow the hand hygiene protocol during the care provided.
Failure to Submit PASRR Level II for Residents with New Mental Health Diagnoses
Penalty
Summary
The facility failed to submit a Preadmission Screening and Resident Review (PASRR) Level II for four residents after new mental illness diagnoses were added. This deficiency was identified through observations, staff interviews, record reviews, and a review of the facility's policy on Resident Assessment-Coordination with PASARR Program. The policy mandates that any resident with a newly evident or possible serious mental disorder should be referred promptly for a Level II resident review. However, the facility did not adhere to this policy for the residents in question. Resident 5 was admitted with various diagnoses, including dementia and PTSD, and later had depression added as a diagnosis. Despite this, the resident's records showed no submission for a PASRR Level II. Similarly, Resident 2, who had multiple mental health diagnoses added over time, also did not have a PASRR Level II submitted. Both residents' records were reviewed by the Director of Operations and the MDS Director, who confirmed the oversight. The new Social Services Director, responsible for submitting PASRRs, was unaware of these residents' diagnoses and PASRR status due to being new in her role. Residents 14 and 294 also had significant mental health diagnoses, including bipolar disorder, but lacked a PASRR Level II submission. Resident 14 exhibited behavioral symptoms and was observed yelling for help, yet no Level II review was initiated. Similarly, Resident 294, with a diagnosis of bipolar disorder, showed behavioral symptoms but was not referred for a Level II review. The Regional Nurse Consultant confirmed that neither resident had a PASRR Level II applied for, indicating a systemic issue in the facility's process for managing PASRR requirements.
Failure to Provide Adequate ADL Care for Residents
Penalty
Summary
The facility failed to provide adequate care and assistance with activities of daily living (ADLs) for three residents, leading to unmet needs and diminished quality of life. Resident 8, who has severe cognitive impairment and requires substantial assistance, had not received a shower in a month due to issues with shower bed transport. Observations revealed that the resident had visible facial hair and unkempt hair, and interviews with staff confirmed the lack of scheduled showers and personal hygiene care. Resident 84, with moderate cognitive impairment and dependence on staff for personal hygiene, was observed with visible facial hair and unkempt hair, as well as fingernails with a brown substance. Despite the care plan indicating the need for assistance with grooming and hygiene, the resident did not receive the necessary care, as evidenced by multiple observations over several days. Resident 294, who requires moderate assistance with personal hygiene, was observed with greasy, unkempt hair and dirty fingernails over several days. The resident reported not being offered assistance with showering, and observations confirmed the lack of hygiene care. The Director of Nursing acknowledged the expectation for staff to provide scheduled ADL care and document any refusals, which was not adhered to in these cases.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a 37.04 percent error rate during the observation of medication administration for one resident. The facility's policy on medication administration, which includes ensuring the six rights of medication administration, was not adhered to. Specifically, medications that were scheduled to be administered at 9:00 am were given late at 10:43 am, and one medication, diltiazem ER 120 mg, was not available for administration. This deviation from the scheduled medication times was confirmed by the Director of Nursing (DON) and the Registered Nurse (RN) involved in the administration. The resident involved, identified as R17, had multiple diagnoses including essential hypertension, metabolic encephalopathy, tachycardia, and anxiety disorder. The resident's physician's orders included several medications to be administered once daily or every morning, all scheduled for 9:00 am. During the observation, it was noted that the medications were administered late, and the RN acknowledged the delay. The DON confirmed that the facility's expectation was for medications to be administered within one hour before or after the scheduled time, which was not met in this instance.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, homelike, and safe environment in one of its units, specifically Unit 2. Observations revealed multiple deficiencies, including cluttered living areas with personal items stored on the floor and overbed tables, exposed sheet rock, chipped sink ledges, and hard-to-open bathroom doors. Privacy curtains were found to have brown spots, and walls had black marks and peeling wallpaper. Additionally, the space between beds was cluttered with wheelchairs, rollators, and clothing items, limiting residents' ability to transfer safely. Further observations in the laundry room revealed missing and water-stained ceiling tiles, a ventilation unit wrapped in aluminum foil-like material secured with duct tape, and insulation spilling out. These conditions were confirmed by the Administrator and the Environmental Services Manager during walking rounds. The facility's policy on maintaining a safe and homelike environment was not adhered to, as housekeeping and maintenance services failed to ensure a sanitary, orderly, and comfortable environment for the residents.
Medication Misappropriation During Administration
Penalty
Summary
The facility failed to ensure that residents' medications were free from misappropriation during medication administration. During an observation, a Registered Nurse (RN) discovered that a resident's prescribed metoprolol extended-release 50 mg was not available on the medication cart. Instead of following the proper protocol to obtain the medication from the facility's backup dispensing system, the RN obtained two metoprolol ER 25 mg tablets from another nurse. This nurse, a Licensed Practical Nurse (LPN), admitted to taking the medication from another resident's medication pack, acknowledging that she knew it was against policy but acted without thinking. The Director of Nursing (DON) later confirmed that the correct procedure, if a medication is unavailable, is to retrieve it from the backup system or contact the pharmacy if it is not available there. The incident highlights a breach in the facility's medication administration policy, which mandates adherence to the six rights of medication administration, including ensuring the right drug and dosage for the right resident. This misappropriation of medication from one resident to another constitutes a failure to protect residents' belongings, specifically their medications, from wrongful use.
Failure to Provide Timely Pharmaceutical Services
Penalty
Summary
The facility failed to ensure timely pharmaceutical services for a resident, identified as R17, who was observed for medication administration. R17 had physician orders for metoprolol ER 50 mg and diltiazem ER 120 mg to be administered in the morning for hypertension. During a medication administration observation, it was noted that these medications were not available in the medication cart. The facility's policy on pharmacy services, which mandates timely acquisition and administration of medications, was not adhered to. Further investigation revealed that the facility did not have a backup pharmacy provider, and the diltiazem ER 120 mg was not available on-site. The LPN stated that the pharmacy would be notified to arrange for the medication, but it would take at least an hour for delivery, missing the scheduled administration time. The DON acknowledged awareness of the issue with timely medication reordering and confirmed the failure to ensure R17's medications were available as ordered by the physician.
Significant Medication Error Due to Unavailability
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as observed during a medication administration review. The facility's policy required medications to be administered within one hour before or after the scheduled time. However, the resident's diltiazem ER 120 mg, prescribed for hypertension, was not available for administration at the scheduled 9:00 am time. The medication was eventually administered after 4:00 pm, significantly outside the allowed timeframe. This delay was confirmed by the RN and LPN involved, as well as the Director of Nursing, who acknowledged the medication was unavailable and not administered as required. The resident involved had a medical history that included essential hypertension, metabolic encephalopathy, tachycardia, and anxiety disorder. The deficiency was identified when the medication was not administered during the observed medication pass at 10:43 am, and the RN confirmed the unavailability of the medication. The LPN and DON both confirmed the medication should have been administered within the specified timeframe, and the delay was noted in the resident's progress notes, indicating the medication was given after the physician was informed of the situation.
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Surveyors found that clean linens and personal clothing were stored and staged in close proximity to the dirty laundry area, with an open door between the clean and soiled sides and all washer and dryer doors open. Clean resident clothes, unlabeled garments, and bagged items were placed next to dryers and directly in front of the dirty linen room, and dirty barrels had to be pushed past racks of clean clothing to reach the washers, contrary to facility policies requiring separation of clean and soiled linens. Environmental staff believed keeping doors open and covering dirty barrels reduced infection spread, while the Environmental Services Director, IP nurse, and Administrator acknowledged that the dirty room door should be closed, linens should not be on dirty barrels, and clean resident clothing should not be stored in that location.
A resident with a suprapubic catheter, colostomy, sacral wound, and dependence on staff for bathing and hygiene was care planned for Enhanced Barrier Precautions (EBP), including use of PPE during high-contact care. During observed catheter care and a bed bath, a CNA wore only gloves and did not don a gown, despite EBP signage and a star posted on the door and PPE supplies available outside the room. In interviews, the CNA admitted forgetting to wear a gown and not recognizing additional required actions, while the IP nurse and DON confirmed that staff had been educated that gowns and gloves are required for high-contact care involving indwelling devices and wounds under the facility’s EBP policy.
A resident with multiple neurologic and psychiatric diagnoses, intact cognition, and unilateral functional limitations was found with an open box of lubricant eye drops stored at the bedside without any documented assessment for self-administration or prescriber’s order for self-administration or bedside storage, contrary to facility policy. Observations on multiple days confirmed the eye drops remained at the bedside, while staff interviews showed that CNAs and the IP recognized that residents were generally not to self-administer medications and that bedside medications required assessment and orders. The Administrator confirmed that the resident should not have had eye drops in the room and that residents with bedside medications are typically assessed for self-administration, and staff acknowledged that unsecured eye drops at the bedside could be accessed or ingested by other residents and cause harm.
The facility failed to maintain a safe, clean environment when multiple ceiling tiles throughout the building, including above a resident’s bed, near the nurses’ station, in a glass day room above a resident’s chair, and in a main hall, were observed with brown circular stains, bulging, and a white moldy substance. The Maintenance Director confirmed the stained and bulging tiles, acknowledged the risk that tiles above a resident’s bed could fall, and attributed the condition to rain-related roof leaks. The Administrator also confirmed that roof leaks and recent rainfall caused the brownish stains despite her reported daily rounds.
A resident with severe cognitive impairment, on hospice and fully dependent for ADLs, was sexually abused when another cognitively impaired male resident with a long-standing history of sexually inappropriate behavior toward female residents entered her room and placed his hand inside her pants. The abusing resident had multiple dementia and psychiatric diagnoses, was care planned for sexually inappropriate behaviors with prior documented incidents, and was on psychotropic medication for OCD-related sexual obsession. Despite these known risks and existing care plan interventions, he was able to access the female resident’s room and make inappropriate physical contact, and the facility’s investigation substantiated the abuse.
Surveyors found that the facility failed to develop and implement complete, person-centered care plans for two residents. One resident was receiving an antipsychotic (Haloperidol) for schizophrenia with associated behavior and side-effect monitoring orders, but there was no corresponding care plan addressing antipsychotic use or its indication. Another resident had an indwelling Foley catheter for neurogenic bladder related to prostate cancer, with goals to prevent catheter-related trauma; however, the care plan omitted key interventions such as balloon volume parameters and use of a leg strap or securement device, despite physician orders requiring a leg strap and observations showing the catheter positioned under the leg without securement. An MDS coordinator and the administrator acknowledged that required interventions and standard catheter care components were missing from the care plans.
A resident with a history of resistiveness to care and noncompliance with the non‑smoking policy had a comprehensive care plan that was not updated to reflect multiple interventions implemented in response to repeated smoking and vaping violations. Although the care plan noted the need for supervision while smoking and review of the smoking policy, it did not include measures such as daily room searches for smoking materials, added smoke detection in the room, relocation closer to the nurses’ station, q2h visual rounds for smoke, post‑outing nursing checks, initiation of a PAR process for vaping, or issuance of a discharge notice. Facility forms showed inconsistent documentation of daily room searches and incomplete IDT documentation on the PAR tracking, despite multiple documented episodes of policy violations and removal of vaping devices.
A cognitively intact but physically impaired resident with a history of noncompliance with the facility’s non‑smoking policy repeatedly smoked and vaped in his room while keeping multiple vape devices and other items at bedside. The facility’s Smoking Policy required that non‑compliant smokers have daily documented searches and be prohibited from keeping smoking materials in their rooms, yet monitoring forms showed many days without documented searches, Patient at Risk tracking was incomplete, and staff acknowledged that daily room checks and frequent rounds were not consistently performed. Multiple staff, including a CNA, social worker, Infection Preventionist, MDS coordinator, Activities Director, and the Administrator, reported ongoing violations and repeated discovery of vape devices in the resident’s room, including during surveyor observations, demonstrating that the environment was not maintained free from accident hazards and that required supervision and monitoring were not reliably implemented.
Surveyors found that a treatment cart containing topical medications was left unlocked and unattended in a hall across from a resident’s room after wound care was completed by an LPN. The facility’s policy requires that medication carts and supplies be locked or attended and accessible only to licensed or otherwise authorized staff. During interviews, the LPN confirmed the cart had been left unlocked and unattended, the IP LPN confirmed the LPN’s report that the cart was left unlocked, and the Administrator stated that all medications, including topical medications, were expected to be locked when not in sight of authorized staff.
The facility failed to implement its infection prevention and control program by not operationalizing a documented Legionella water management plan despite having a written policy, and by not fully implementing Enhanced Barrier Precautions (EBP) for residents with indwelling devices and other risks. A resident with an indwelling urinary catheter had no EBP care plan or orders, no EBP signage, and staff providing catheter care wore only gloves without gowns, while multiple staff members reported not knowing what EBP was or misidentified who should be on EBP. Another resident receiving tube feeding had care initiated by an LPN who wore gloves but no gown and repeatedly touched her hair with the same gloved hands before handling the feeding tube and equipment, later acknowledging she should have changed gloves and was unaware of EBP requirements, even though other clinical staff stated gowns and gloves should be used for feeding tube care. A resident on isolation for C. diff had a door sign indicating isolation but no instructions for visitors on required PPE or to seek staff guidance, and the IP confirmed there was no system to direct visitors about precautions, contributing to the overall infection control deficiency.
Failure to Maintain Separation of Clean and Soiled Laundry
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to separation of clean and soiled linens. Facility policies titled “Infection Prevention and Control Program” and “Handling Soiled Linens” required that clean linen always be separated from soiled linen. During an observation of the laundry area, all washer and dryer doors were open in the clean linen area. Clean linens, including sheets, towels, blankets, and washcloths, were folded on a table to the left of the washer and dryer room. On the right side of the room, next to the dryers and directly in front of the open door to the dirty laundry room, there were residents’ clean clothes on a rack, piles of folded clean clothes to be hung, a rack of unlabeled clothes, and a bag of unlabeled clothes. Dirty laundry barrels had to be pushed past the clean clothing on the racks to reach the washers, placing soiled items in close proximity to clean items despite policy requirements for separation. Environmental staff working in the laundry stated they believed they were reducing the spread of infection by keeping all doors open, covering dirty barrels, and circulating air, and they explained that the uncovered rack and bagged clothes near the dirty area were no-name clothes sometimes distributed to residents in need. They also stated that the rack of clean personal resident clothing parked in front of the open dirty linen room door was awaiting distribution by a staff member who worked only at night. The Environmental Services Director reported that the door to the dirty side of the laundry should always be closed and that no linen should be on top of dirty barrels. The Infection Preventionist nurse, when shown pictures and concerns about cross-contamination, confirmed there was a problem in the laundry but stated she had not been aware of it previously. The Administrator stated that residents’ clothes should not be stored where they were observed and should be handed out immediately once clean, and that she expected the laundry to be organized to prevent cross-contamination between dirty and clean clothes.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff followed its Enhanced Barrier Precautions (EBP) policy for the use of personal protective equipment (PPE) during high-contact care. The facility’s EBP policy, updated February 2025, requires gowns and gloves for residents with wounds and/or indwelling medical devices, including urinary catheters and ostomies, when staff perform high-contact activities such as bathing, dressing, toileting, hygiene, and catheter care. The policy also directs that gowns and gloves be made available near or outside the resident’s room and that EBP be implemented for residents with indwelling devices or wounds, even if they are not known to be infected or colonized with a multidrug-resistant organism. The resident involved had a suprapubic catheter, colostomy, sacral wound, and neurogenic bladder and bowel, and was care planned for EBP implementation during catheter and skin care. The resident was cognitively intact but dependent on staff for bathing, dressing, toileting, hygiene, bed mobility, and transfers, and used an indwelling catheter and ostomy. During an observation, a CNA provided suprapubic catheter care and a bed bath to this resident while only wearing gloves, despite EBP signage and a star posted on the door and PPE supplies available outside the room. The CNA did not don a gown and was unable to identify any additional actions needed before care until prompted about the EBP signage, at which point he acknowledged he should have worn a gown but forgot. In a subsequent interview, the IP nurse and DON confirmed that staff had been educated that gowns are required during high-contact care for residents with catheters, colostomies, and other devices, and that the posted signage and star were intended to alert staff to the need for enhanced PPE use.
Failure to Assess and Obtain Orders for Self-Administration and Bedside Medication Storage
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policies for self-administration of medications and bedside medication storage for one resident. The facility’s policies require that residents who wish to self-administer medications must be assessed by the interdisciplinary team for cognitive, physical, and visual ability, and that a prescriber’s order for self-administration and bedside storage must be present in the medical record and reflected on the MAR and medication label. For the resident in question, who had diagnoses including cerebral infarction, major depressive disorder with psychotic symptoms, PTSD, hemiplegia and hemiparesis, speech and language deficits, and cerebral atherosclerosis, the EHR showed no assessment for self-administration and no physician order for self-administration or bedside storage, despite active ophthalmic medication orders. The resident’s MDS documented intact cognition with a BIMS score of 15, use of corrective lenses, and functional limitations in range of motion on one side of both upper and lower extremities. Surveyor observations on two consecutive days found an open box of lubricant eye drops on the resident’s bedside table. Staff interviews revealed inconsistent understanding and enforcement of the facility’s policies. A CNA stated that residents did not self-administer medications and that only nurses administered them, but also reported that when she previously reported the eye drops, she was told the resident could have them because he was independent. The Infection Preventionist acknowledged the resident had an order for eye drops and believed he obtained them from the VA, and stated he should not have the lubricant eye drops because they were a hazard for other people. The Administrator confirmed that typically a resident with medications at the bedside should be assessed for self-administration and stated the resident should not have eye drops in his room. The report notes that unsecured medications at the bedside had the potential to cause adverse reactions if accessed or ingested by other residents.
Failure to Maintain Safe and Clean Ceiling Surfaces Throughout Facility
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable homelike environment as required by its Maintenance Service policy, which assigns the Maintenance Department responsibility for keeping the building in good repair and free from hazards. Surveyors observed multiple stained and damaged ceiling tiles in several areas of the facility, including near the nurses' station, in a resident bedroom (room [ROOM NUMBER]A), in the glass day room, and in the middle of the east hall. On several occasions, ceiling tiles near the nurses' station were noted to have tannish-brown circular stains of varying sizes, and at one point a white, moldy substance was observed on a ceiling tile in that same area. In room [ROOM NUMBER]A, surveyors observed brown rings roughly 16 inches in diameter on ceiling tiles located directly above a resident’s bed, with the Maintenance Director later confirming that these tiles were stained, bulging, and at risk of falling on the resident. Additional observations in the glass day room identified two stained ceiling tiles above a resident’s chair, each with brown circular stains approximately three inches in diameter. In the east hall, a ceiling tile with a brown circular stain approximately 10 inches in diameter was also documented. The Maintenance Director and the Administrator both acknowledged that the stains and damage were related to roof leaks associated with recent rainfall, and the Administrator confirmed awareness of roof leaks that had previously been repaired and that the brownish stains were due to recent rain.
Failure to Prevent Sexual Abuse of a Cognitively Impaired Resident by Another Resident
Penalty
Summary
The facility failed to protect a dependent, cognitively impaired resident (R113) from sexual abuse by another resident (R12). R113 had severe cognitive impairment with a BIMS score of 5, was on hospice care, and was fully dependent for toileting, bathing, dressing, footwear, and personal hygiene. On the day of the incident, a CNA observed R12 in R113’s room with his right hand inside R113’s pants while she was seated in a geriatric chair. Staff witness statements and nursing progress notes documented that R12 was found in R113’s room with his hand in her pants, and the facility’s investigation substantiated that R12 touched R113 inappropriately. R12 also had severe cognitive impairment with a BIMS score of 4 and multiple psychiatric and dementia-related diagnoses, including vascular dementia with mood disturbance, Alzheimer’s disease, major depressive disorder, obsessive-compulsive personality disorder, unspecified psychosis, and unspecified mood affective disorder. He required extensive physical assistance, used a manual wheelchair, and was fully dependent for toileting, bathing, lower body dressing, and footwear. R12’s care plan, in place since 2017, identified him as having sexually verbally and physically inappropriate behavior, including documented prior incidents in which he inappropriately touched or attempted to touch female residents. His care plan included interventions such as discussing his behavior when reasonable, explaining that it was inappropriate, intervening to protect others, diverting his attention, and removing him from situations as needed, as well as monitoring and recording occurrences of target behaviors such as sexual aggression toward others. Despite this known history of sexually inappropriate behavior toward female residents and the presence of care plan interventions, R12 was able to enter R113’s room and place his hand inside her pants. The Administrator confirmed that the CNA reported finding R12 in R113’s room with his hand in her pants while R113 was in her wheelchair, and that the facility’s investigation substantiated the abuse allegation. The facility’s abuse policy stated that it would not condone resident abuse by anyone, including other residents, and defined sexual abuse to include sexual harassment, sexual coercion, or sexual assault. The occurrence of this incident demonstrated that the facility did not effectively prevent sexual abuse of R113 by another resident, despite R12’s documented behavioral history and existing care plan.
Failure to Develop and Implement Complete Care Plans for Antipsychotic Use and Foley Catheter Management
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for identified resident needs, as required by its Comprehensive Care Plan policy. The policy states that care plans must address all needs identified in the comprehensive assessment, including medical, nursing, mental, and psychosocial needs, and must be developed within seven days after completion of the comprehensive MDS assessment. It also requires that all triggered Care Area Assessments (CAAs) and other factors identified by the IDT or resident preferences be incorporated into the plan of care. For one resident, R44, the clinical record showed physician orders for Haloperidol 10 mg by mouth twice daily for schizophrenia, along with orders for behavior monitoring and psychiatric medication side effect monitoring. Despite these orders, the resident’s care plan dated 03/11/2026 did not include any care plan addressing antipsychotic medication use or its indication. The MDS Coordinator stated that all residents receiving antipsychotic treatment should have a comprehensive care plan in place beginning with the date the medication was originally ordered, and upon review of the record confirmed that such a care plan was not present for this resident at the time of the survey. For another resident, R3, the care plan dated 03/13/2026 identified a problem of an indwelling catheter secondary to neurogenic bladder related to prostate cancer, with goals including remaining free from catheter-related trauma. The listed interventions included positioning the catheter bag and tubing below bladder level, monitoring and documenting intake and output per policy, and monitoring for pain, discomfort, and signs and symptoms of UTI. However, the care plan did not address the amount of water in the catheter balloon, use of a leg strap or securement device, or other securement measures. Physician orders specified checking a leg strap every shift and documented that the resident was admitted with an 18F catheter attached to a bedside drainage bag, but observations showed the Foley catheter positioned under the resident’s leg without a leg strap or securement device on two occasions, and a CNA reported being unaware that a leg strap was required. The MDS Coordinator confirmed that these ordered interventions were missing from the care plan.
Failure to Revise Care Plan for Ongoing Smoking Policy Noncompliance
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive care plan to reflect current interventions implemented in response to ongoing noncompliance with the facility’s non‑smoking policy. The facility’s policy requires that the comprehensive care plan be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment, and that it include measurable objectives, timeframes, and alternative interventions as needed, with qualified staff notified when changes are made. The resident’s care plan included a focus on resistiveness to care and noncompliance with smoking, noting that the resident continued to go outside beyond facility property to smoke, and an intervention to review the smoking policy with the resident. Another care plan focus identified the resident as a smoker requiring supervision while smoking, with interventions stating the resident required supervision while smoking and that the charge nurse should be notified if a smoking policy violation was suspected. Despite repeated and ongoing noncompliance with the non‑smoking policy, the care plan was not revised to include additional interventions that were actually implemented. These unreflected interventions included daily room searches for smoking paraphernalia, placement of a smoke detector in the resident’s room, relocation of the resident’s room closer to the nursing station, every‑two‑hour visual rounds to check for smoke, nursing checks upon return from outings, initiation of a Patient at Risk (PAR) process for vaping noncompliance, and issuance of a 30‑day discharge notice for repeated violations of the non‑smoking policy. Documentation on the Smoking Materials Monitoring Form showed initials on selected days only, indicating daily room searches were not consistently completed and documented for the entire month. The PAR Smoking Tracking form documented multiple observations of vaping in the room, repeated room checks, removal of vapor devices, and the resident’s refusal to comply with facility policies, with later weeks lacking IDT signatures and documentation, while the PAR Grid showed multiple prior entries for violating the non‑smoking policy.
Failure to Control Smoking and Vaping Hazards for a Noncompliant Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision for a resident with a known history of noncompliance with the facility’s non‑smoking policy. The facility’s Smoking Policy requires that residents not be allowed to keep cigarettes, cigars, pipes, matches, or lighters in their possession or rooms, and that non‑compliant smokers receive daily searches with documentation, while compliant smokers receive weekly searches. The policy also requires incident reports and review in a “Patients at Risk” process whenever smoking materials are found. Despite these written procedures, the resident’s Smoking Materials Monitoring Form for April showed multiple days without documented searches, indicating that required daily room searches were not consistently completed or recorded. The resident at issue was cognitively intact, with a BIMS score of 15, and had significant physical impairments including hemiplegia and hemiparesis on the left side, use of a manual wheelchair, and other neurologic and psychiatric diagnoses such as cerebral aneurysm, cerebral infarction, major depressive disorder with psychotic symptoms, PTSD, and speech and language deficits. The care plan identified the resident as resistive to care and noncompliant with smoking, noting that he continued to go outside beyond facility property to smoke, and also identified him as a smoker requiring supervision while smoking. Progress notes and Patient at Risk documentation showed a pattern of repeated violations of the non‑smoking policy, including multiple instances of vaping and smoking in his room, with staff repeatedly finding vape devices and other smoking paraphernalia in his possession and in his room. Throughout the period reviewed, staff observations and interviews confirmed ongoing noncompliance with the smoking policy and inconsistent implementation of the facility’s own interventions. Staff documented several occasions when the resident was observed vaping or smoking in his room, including in the presence of a state surveyor, and room searches revealed multiple vape devices hidden under the sheets. Staff interviews indicated that daily room checks were not always performed due to competing demands, that logs of every‑two‑hour rounds were not maintained, and that there was confusion or inconsistency regarding whether the resident could keep items such as air freshener at bedside. The social worker, Infection Preventionist, MDS coordinator, Activities Director, CNA, and Administrator all acknowledged that the resident’s room had to be searched for cigarettes and vaping paraphernalia and that prohibited items were repeatedly found, while documentation showed gaps in the required daily searches and incomplete follow‑through on the Patient at Risk tracking process. These actions and inactions resulted in the environment not being kept free from accident hazards as required by the facility’s policy and regulatory standards. The deficiency is further supported by the facility’s own records showing repeated entries on the Patient at Risk grid for violations of the non‑smoking policy over an extended period, as well as narrative notes describing the resident’s statements that he would continue to vape in his room and would simply obtain new devices if they were confiscated. Despite the known pattern of behavior and the facility’s policy requiring close supervision, daily searches, and thorough documentation for non‑compliant smokers, the monitoring forms and staff interviews demonstrate that these measures were not consistently carried out. The presence of multiple vape devices and cans of air freshener at the bedside during surveyor observations, along with staff acknowledgment that room checks were missed and that logs of frequent rounds were not kept, illustrate the facility’s failure to effectively implement its own safety procedures to prevent accident hazards related to smoking and vaping in the resident’s room.
Unlocked and Unattended Treatment Cart with Topical Medications
Penalty
Summary
Surveyors identified a deficiency related to medication storage when a treatment cart containing topical medications was left unlocked and unattended in a hall. The facility’s policy titled “Medication Storage in the Facility,” effective 10/01/2025, states that the medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff lawfully authorized to administer medications, and that medication rooms, carts, and supplies are to be locked or attended by authorized personnel. During an observation on 04/29/2026 at 9:35 AM, after wound care was provided to resident R3 by the wound care LPN, the treatment cart was observed left in the [NAME] hall across from R3’s room, unlocked and unattended for 30 minutes. In an interview, the wound care LPN confirmed that the treatment cart had been left unlocked and unattended. The Infection Preventionist LPN later confirmed that the wound care nurse told her the cart was left unlocked, and the Administrator stated that her expectation was that all medications, including topical medications, be locked when not in sight of a licensed nurse or authorized person. This deficient practice occurred in a facility with a census of 94 residents and involved the failure to follow the facility’s own policy requiring that medication carts be locked or attended by authorized personnel, resulting in unsecured access to topical medications on the treatment cart.
Failure to Implement Legionella Water Management and Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to provide and implement an infection prevention and control program, including a documented water management plan for Legionella and other waterborne pathogens, and a fully implemented Enhanced Barrier Precautions (EBP) program. The Administrator stated there was no Legionella water program in place, and the Maintenance Supervisor reported he was unaware of the requirement for such a program. This was despite the existence of a written Legionella Water Management Program policy, revised in September 2022, which described the need for an interdisciplinary water management team, detailed water system diagrams, identification of risk areas and situations for Legionella growth, control measures, monitoring systems, and annual review. Interviews confirmed that the expectation was that the facility would be conducting this water program, but it was not being done. The facility also failed to implement EBP for residents with indwelling medical devices and other risk factors, as required by its own policy. One resident with Alzheimer’s disease, urinary obstruction, and emphysema had an indwelling urinary catheter documented in the care plan and physician orders, but the care plan did not address EBP related to the catheter, and there was no order for EBP in the record. During catheter-related care, a CNA wore gloves but did not wear a gown, and there was no EBP signage or PPE setup at the room. Multiple staff members, including CNAs and a housekeeper who regularly worked on the resident’s hallway, reported they did not know what EBP was or incorrectly associated EBP only with residents on Transmission-Based Precautions. The DON acknowledged that an attempt to roll out EBP months earlier had not been completed, and that expected signage and PPE caddies for EBP were not fully in place. Additional infection control lapses were observed during tube feeding care and contact isolation. A resident receiving continuous tube feeding had a care plan and physician’s order for enteral nutrition, and an LPN initiated the feeding while wearing gloves but no gown. During the procedure, the LPN repeatedly touched her hair with the same gloved hands and then handled the feeding tube, pump, and syringe used to inject air and check residuals, only removing gloves and using hand sanitizer at the end. The LPN later acknowledged she should have changed gloves after touching her hair and stated she did not know what EBP was or that a gown was required for feeding tube care, while another LPN and the IP stated that EBP with gown and gloves should be used for feeding tube care and that staff should not touch their hair during care without changing gloves and performing hand hygiene. For a resident with a positive urine culture and a subsequent positive C. difficile culture who was on isolation, the door sign indicated isolation but did not provide instructions for visitors on required precautions or direct them to staff for guidance. The IP confirmed there was no system to direct visitors about PPE use for residents on contact isolation and acknowledged that visitors would not know to wear PPE if it was simply present in or on the door of the room. Overall, the survey findings show that the facility did not operationalize its written Legionella water management policy and did not consistently apply its EBP policy for residents with indwelling devices or wounds. Staff interviews and observations demonstrated a lack of knowledge and implementation of EBP, incomplete use of PPE during high-contact care activities such as catheter care and tube feeding, and unclear isolation signage that did not instruct visitors on appropriate precautions. These combined inactions and omissions in policy implementation, staff education, and practice led to the cited infection prevention and control deficiency.
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