Blue Ridge Care Center Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Dallas, Georgia.
- Location
- 600 West Memorial Drive, Dallas, Georgia 30132
- CMS Provider Number
- 115258
- Inspections on file
- 20
- Latest survey
- December 7, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Blue Ridge Care Center Llc during CMS and state inspections, most recent first.
Dietary staff did not label or date opened food items and failed to properly discard expired milk. Unlabeled opened cheese and teriyaki sauce were found in storage, and expired chocolate milk was stored with other milk without appropriate signage. The DOD confirmed these lapses and acknowledged responsibility for oversight.
Surveyors found that the facility's dish machine was not properly sanitizing dishware, as temperature gauges were not functioning and sanitizer was not being dispensed, despite multiple tests and recent repairs. This deficiency was identified while nearly all residents were receiving oral diets, and was confirmed through staff interviews and direct observation.
A resident with paraplegia and severe cognitive impairment had personal and medical information posted on their wall, including birthday, gender, medical ID, and a picture. This posting was observed on multiple occasions, and interviews with a family member, the UM, and the DON confirmed that such information should not have been displayed, violating privacy policies.
A resident with depression, anxiety, and other medical conditions received PRN alprazolam for anxiety beyond the 14-day limit required by facility policy. The order was entered with an indefinite stop date, and the medication was administered on multiple occasions past the allowed timeframe. Staff confirmed the expectation for a 14-day limit on PRN psychotropic medications, but the order and administration did not comply with this policy.
The facility did not develop or implement comprehensive care plans for four residents with specialized needs, including those with indwelling urinary catheters, oxygen therapy, and psychotropic medication use. Despite physician orders and documented assessments, care plans lacked necessary focus areas and interventions, as confirmed by staff interviews and record reviews.
A resident with severe cognitive impairment and protein calorie malnutrition was not given a physician-ordered frozen nutritional supplement with meals due to a supply shortage and miscommunication among dietary staff. The supplement was omitted from the resident's lunch tray, and no alternative was provided, despite facility policy requiring supplements to meet assessed needs.
Two residents received oxygen therapy not in accordance with physician orders, including continuous administration when only as-needed use was ordered and at higher flow rates than prescribed. Staff failed to document oxygen administration and did not specify whether oxygen saturation readings were on room air or oxygen. Additionally, required equipment maintenance and safety signage were not followed, as oxygen concentrators lacked filters and 'oxygen in use' signs were missing.
A resident with severe cognitive impairment and a diagnosis of protein calorie malnutrition was not served the lunch meal as written on the facility menu or tray slip. Instead of chicken parmesan, the resident received plain steamed chicken, despite staff and family confirming the discrepancy. Both the Administrator and DOD acknowledged the resident should have received chicken parmesan without sauce, as is the usual practice for residents preferring no sauces.
A CNA did not follow proper hand hygiene and glove-changing protocols while providing catheter care to a resident with an indwelling urinary catheter. The CNA performed care tasks without washing or sanitizing hands between steps and did not change gloves as required, contrary to facility policy and physician orders.
The facility did not revise its CLIA certificate within the required 30 days after a change in ownership, continuing to operate under the previous owner's certificate for approximately seven months. The Administrator confirmed the ongoing use of the prior waiver, and the State CLIA Department verified the facility was out of compliance.
Surveyors observed that bath linens provided to residents were often torn, tattered, or insufficient across multiple hallways. Staff and residents reported frequent shortages, with some towels being cut up to make washcloths. Linen carts were found lacking, and several residents displayed damaged linens from their rooms. Facility leadership acknowledged that such linens should not be used.
Surveyors observed expired food items, including a loaf of bread with visible mold and sandwiches and apples past their use-by dates, stored in resident snack areas on two units. Staff confirmed these items should have been discarded per facility policy, indicating a failure to follow professional standards for food storage and safety.
A CNA assisted multiple residents with eating without performing hand hygiene before or between assisting different individuals, despite touching her own hair, face, cell phone, and food directly with bare hands. Interviews with staff and review of facility policy confirmed that hand hygiene was required before and after assisting with meals, but these protocols were not followed during the observed lunch meal service.
A resident was observed eating at a table that was too high, with her upper lip at table height, making it difficult for her to see her food and eat independently. Staff interviews confirmed that the resident should have been seated at a smaller or adjustable table to promote dignity and facilitate eating.
The facility failed to maintain clean oxygen concentrator filters for two residents requiring oxygen therapy. Observations revealed that the filters were covered with a thick, white substance, indicating they had not been cleaned as required by the facility's policy. Interviews with staff confirmed the deficiency, highlighting a lapse in adherence to the maintenance schedule.
Failure to Label Opened Food Items and Discard Expired Milk
Penalty
Summary
Dietary staff failed to label and date opened food items and did not properly discard expired milk, as required by facility policy. Observations revealed a five-pound bag of shredded cheddar cheese and a one-gallon container of teriyaki sauce that had been opened and stored without an open date. The Director of Dietary (DOD) confirmed these items were not labeled as required and stated that all dietary staff were responsible for labeling and dating, but she was ultimately responsible for checking compliance. The DOD had not yet checked the walk-in refrigerator on the day of the observation. Additionally, a full crate of eight-ounce chocolate milk cartons with a sell-by date that had passed was found stored next to other milk crates without a 'do not use' sign. The DOD acknowledged that expired milk should be separated and marked accordingly but admitted to noticing the expired crate and forgetting to move it and label it. At the time of the survey, the facility census was 163, with 162 residents receiving an oral diet.
Failure to Maintain Proper Dish Machine Sanitization
Penalty
Summary
The facility failed to ensure that the dish machine used for sanitizing dishware was functioning properly to prevent foodborne illness. Observations revealed that the large conveyor belt type dish machine, which operates as a low temperature chemical sanitizing unit, had non-functioning temperature gauges and was not dispersing sanitizer as required by facility policy. Multiple attempts to test the sanitizing solution using paper test strips showed no indication of sanitizer being present, as the strips remained white instead of turning black to indicate the required concentration. Staff, including the dietary aide, Director of Dietary (DOD), and Director of Maintenance (DOM), confirmed these findings during the survey. The issue persisted despite staff checking chemical buckets, tubing, and replacing the sanitizer bucket. The temperature gauges on the dish machine were also not registering any temperatures for the wash or rinse cycles during several observations. The DOD and DOM both confirmed that the dish machine had recently undergone repairs and had been out of operation for several days while waiting for a part. However, even after the machine was reported as fixed and the temperature gauges began working again, repeated tests continued to show no sanitizer being dispensed. The deficiency was observed while 162 out of 163 residents were receiving an oral diet, indicating that the majority of residents could have been affected by improperly sanitized dishware. The failure to maintain essential equipment in safe working order was confirmed through direct observation, staff interviews, and review of facility policy, with the dish machine only beginning to dispense sanitizer after multiple interventions and repeated testing.
Failure to Protect Resident Health Information Privacy
Penalty
Summary
The facility failed to protect the privacy of a resident's health information by posting instructions on the resident's wall that disclosed personal details, including birthday, gender, medical identification, and a picture. This posting was observed on two separate occasions and was titled with the resident's shower day, making private medical information visible. The facility's policy on promoting and maintaining residents' dignity specifically requires maintaining resident privacy, which was not followed in this instance. The resident involved had a diagnosis of paraplegia and severe cognitive impairment, as indicated by a BIMS score of 00 on the most recent assessment. Interviews with a family member, the Unit Manager, and the DON confirmed that the posting of such information was inappropriate and not in line with facility policy or HIPAA requirements. The family member was unaware of the posting, and both the Unit Manager and DON acknowledged that staff should not post residents' medical information in this manner.
Failure to Limit PRN Psychotropic Medication Orders to 14 Days
Penalty
Summary
The facility failed to ensure that as-needed (PRN) psychotropic medication orders were limited to 14 days as required by policy for one resident. The policy on the use of psychotropic medications specified that PRN orders should not exceed 14 days unless the prescriber documents a rationale for extending the order and specifies a duration. However, a review of the electronic medical record (EMR) for a resident with diagnoses including depression, anxiety, diabetes mellitus type 2, and urinary tract infection revealed an order for alprazolam 0.25 mg every 12 hours as needed for anxiety, with an indefinite stop date. The resident was cognitively intact, as indicated by a BIMS score of 15, and the care plan did not address the use of antianxiety or antidepressant medications. Medication administration records showed that alprazolam was administered multiple times beyond the 14-day limit set by policy, with doses given on several dates in both November and December after the initial order date. Staff interviews confirmed that PRN psychotropic medications are expected to be limited to 14 days, but the order in question was entered with an indefinite stop date by the Nurse Practitioner. Both the LPN and DON verified that the medication was administered outside the required timeframe, confirming the deficiency in following the facility's policy regarding PRN psychotropic medication orders.
Failure to Develop Comprehensive Care Plans for Residents with Specialized Needs
Penalty
Summary
The facility failed to develop and implement person-centered comprehensive care plans for four residents, as required by facility policy and professional standards. Specifically, one resident with an indwelling urinary catheter did not have a care plan addressing catheter care, despite physician orders detailing the need for ongoing catheter management and enhanced barrier precautions. The MDS Coordinator confirmed that no care plan was in place for this resident, acknowledging that such a plan should have been completed following the admission assessment. Two other residents who were receiving oxygen therapy also lacked care plans addressing their oxygen use. Both residents had documented orders for oxygen administration and were observed receiving oxygen during the survey. Staff interviews confirmed that the care plans did not include focus areas or interventions related to oxygen therapy, even though this was documented in their assessments. The DON and MDS Coordinator both verified that oxygen use should have been included in the care plans for these residents. A fourth resident, who was prescribed antianxiety, antidepressant, and hypoglycemic medications, did not have a care plan addressing the use of these psychotropic and high-risk medications. The resident's medication use was documented in the MDS assessment, but the care plan lacked any focus areas, goals, or interventions related to these medications. Multiple staff members, including LPNs and the DON, confirmed that interventions for these medications should have been present in the care plan and were unable to explain why they were missing.
Failure to Provide Ordered Nutritional Supplement with Meals
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of unspecified protein calorie malnutrition was not provided with a physician-ordered frozen nutritional supplement during a lunch meal. The resident had a severely impaired cognitive status, as indicated by a Brief Interview for Mental Status (BIMS) score of one out of 15. Review of the resident's electronic medical record confirmed an active order for the supplement to be given with meals. During observation, the lunch tray did not include the supplement, and the resident was only offered a meal plate, iced tea, and Italian ice. The resident's family member confirmed the absence of the supplement and noted that the resident had previously received and enjoyed it. Interviews with facility staff revealed that the dietary department was out of the frozen nutritional supplement and was awaiting a new supply from their food supplier. The Director of Dietary (DOD) was unaware that the supplement was to be given with meals, mistakenly believing it was to be provided between meals. The registered dietitian confirmed the supply issue and stated that the resident had previously refused liquid supplements, but no alternative, such as regular ice cream, was offered during the shortage. The facility's policy required providing nutritional supplements consistent with assessed needs, but this was not followed in this instance.
Failure to Administer Oxygen Therapy as Ordered and Maintain Equipment Protocols
Penalty
Summary
The facility failed to ensure that oxygen was administered as ordered by the physician for two residents who were receiving oxygen therapy. For one resident with diagnoses including epilepsy, acute respiratory distress, and pneumonia, the physician's order specified oxygen at two liters per minute (LPM) via nasal cannula (NC) only if oxygen saturation fell below 90%, with instructions to call the physician immediately after placement. However, the resident was observed receiving oxygen at four LPM continuously, despite no documentation of oxygen saturations below 90% or respiratory distress, and staff confirmed there were no changes in orders or status to justify this deviation. For another resident with shortness of breath and asthma, the physician's order was for oxygen at two LPM via NC as needed for oxygen saturation below 90%, with a requirement to call the physician after placement. This resident was observed receiving continuous oxygen, and staff confirmed that the order was for as-needed use, not continuous administration. Additionally, there was no care plan addressing oxygen use for this resident, and documentation did not specify whether pulse oximeter readings were taken on room air or while on oxygen. Staff also failed to document the administration of oxygen as required by the as-needed order. Further deficiencies were observed in the maintenance and safety protocols for oxygen therapy. The oxygen concentrator for the second resident was missing a required filter, which should have been cleaned or replaced weekly according to physician orders. There was also no 'oxygen in use' signage on the resident's doorway, as required by facility policy. Staff interviews confirmed these lapses in following physician orders and facility protocols for oxygen administration and equipment maintenance.
Failure to Serve Menu Meal as Written for Resident with Malnutrition
Penalty
Summary
The facility failed to serve a lunch meal as written on the menu for one sampled resident who had a diagnosis including unspecified protein calorie malnutrition and severely impaired cognition. The resident had a physician order for a regular diet, regular texture, and regular consistency. According to the facility's posted menu, the lunch meal was supposed to include chicken parmesan, spaghetti, tomato sauce, Italian mixed vegetables, garlic roll, margarine, Italian ice, and whole milk. However, the resident's meal tray slip listed substitutions, including fried chicken with no sauce, noodles with no gravy, and other items. Observation revealed the resident was served plain steamed chicken thigh, Italian mixed vegetables, garlic bread, iced tea, and Italian ice, rather than the chicken parmesan specified on both the menu and the tray slip. Interviews with the resident's family member, the Administrator, and the Director of Dietary confirmed that the resident was not served the chicken parmesan as indicated. The family member reported that the resident was often not served what was indicated on the meal tray slip. Both the Administrator and the Director of Dietary acknowledged that, despite the resident's preference for no sauces or gravy, the resident should have been served chicken parmesan without sauce, as per the menu and tray slip. The Director of Dietary also stated that cooks typically set aside unsauced chicken parmesan for residents who prefer no sauces, but this was not done in this instance.
Failure to Follow Hand Hygiene Protocol During Catheter Care
Penalty
Summary
A deficiency was identified when a Certified Nursing Assistant (CNA) failed to follow proper infection control practices during catheter care for a resident with an indwelling urinary catheter. The CNA was observed double-gloving before entering the resident's room and did not clean the bedside table before setting up supplies. During the catheter care process, the CNA removed only the outer pair of gloves after cleaning the catheter insertion site but continued the remainder of the care, including rinsing, drying, and repositioning the resident, with the same inner gloves. At no point during the procedure did the CNA wash or sanitize her hands when transitioning between clean and dirty tasks, nor did she don new gloves as required by facility policy and professional practice standards. The resident involved had a history of urinary retention, severely impaired cognition, and was dependent on staff for all activities of daily living. The resident's care plan did not include specific interventions for the indwelling urinary catheter, despite physician orders outlining catheter care and enhanced barrier precautions. Facility policy and audit tools specifically required hand hygiene and glove changes during catheter care, but these protocols were not followed during the observed incident.
Failure to Update CLIA Certificate After Change of Ownership
Penalty
Summary
The facility failed to update its Clinical Laboratory Improvement Amendments (CLIA) certificate within 30 days following a change in ownership, as required by regulations. Approximately seven months after the new owner acquired the facility, the CLIA Certificate of Waiver and the CLIA Certificate of Compliance remained in the name of the previous owner and previous laboratory service owner, respectively. During an interview, the facility's Administrator acknowledged that the facility was still operating under the previous owner's waiver as part of the transition. The State CLIA Department confirmed that the facility was out of compliance and should have requested a revised CLIA certificate using the CMS-116 application within the required timeframe.
Failure to Provide Adequate and Clean Bath Linens
Penalty
Summary
Surveyors found that the facility failed to provide bath linens in good condition across seven of nine hallways. During multiple observations, linen carts were found to have either no towels or washcloths, or only those that were torn and in disrepair. Staff were seen using tattered washcloths, and some reported that they often lacked adequate linens, with new linens only being provided during the survey. Residents confirmed that towels had been cut up to make washcloths, and several displayed torn and shredded linens from their personal supplies. Resident Council minutes and grievance logs documented ongoing complaints about daily linen shortages affecting all units. Interviews with staff and administration revealed that families and residents had been cutting up towels to create washcloths, and that staff sometimes had to ration or redistribute available linens. The Environmental Service Supervisor and Administrator acknowledged the issue, with the Administrator stating that linens should not be cut up or used in a damaged state. Photographic evidence of shredded washcloths was presented to facility leadership, who agreed that such items should not be in use.
Expired Food Found in Resident Snack Storage Areas
Penalty
Summary
Staff failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, as evidenced by the presence of expired food in resident snack storage areas. On two separate units, surveyors observed an unopened loaf of bread with an expiration date several months past, which was hard and showed green discoloration, and a refrigerator containing turkey sandwiches and cups of apples that were past their use-by dates. Staff interviews confirmed that these food items should have been discarded according to facility policy, which requires perishable and leftover foods to be labeled with preparation and discard dates and disposed of within a specified timeframe.
Failure to Perform Hand Hygiene During Meal Assistance
Penalty
Summary
Staff failed to perform proper hand hygiene during the lunch meal service in the Nursing Unit Main Dining Room, as observed with three residents. A Certified Nursing Assistant (CNA) assisted residents with eating without using hand sanitizer or washing hands before or between assisting different residents. The CNA was observed touching her own hair, face, and cell phone, as well as handling utensils and food directly with bare hands, and then continuing to assist residents with their meals without performing hand hygiene. The CNA also distributed meal trays and adjusted the television without washing hands before returning to assist residents with eating. Interviews with the CNA, the Nursing Unit Manager (LPN), the Director of Nursing (DON), and facility administrators confirmed that staff are expected to use hand sanitizer or wash hands before serving or feeding residents, and after touching their face or hair. The facility's policy on hand hygiene requires the use of alcohol-based hand rub before and after assisting a resident with meals. The observed failure to follow these protocols occurred during the lunch meal and involved multiple residents who required assistance with eating.
Failure to Provide Appropriate Table Height Compromises Resident Dignity During Meals
Penalty
Summary
A deficiency occurred when a resident was not provided with a dining table of appropriate height, resulting in the resident being unable to see her food while eating. Observations showed the resident seated in a lowered wheelchair at a table where her upper lip was at table height, making it difficult for her to eat independently and with dignity. Staff interviews confirmed awareness of the issue, with a CNA noting that the resident should have been seated at a smaller table to allow her to see her food. The DON and Administrator acknowledged that the resident should have been provided with an adjustable or smaller table, and the Regional Director of Operations also stated that the resident should sit at a smaller table. The failure to provide a suitable table height compromised the resident's dignity during mealtime.
Failure to Maintain Clean Oxygen Concentrator Filters
Penalty
Summary
The facility failed to maintain a clean oxygen concentrator filter for two residents, R56 and R119, who required oxygen therapy. The facility's policy mandated that the oxygen concentrator filter be cleaned weekly and as needed, with documentation on the Medication Administration Record (MAR). However, observations revealed that the filters on both residents' oxygen concentrators were covered with a thick, white substance, indicating they had not been cleaned as required. Interviews with staff, including the Dementia Unit Manager and the Director of Nursing, confirmed that the filters appeared unclean and that the maintenance was supposed to be conducted by the third shift nurse every Wednesday and as needed. R56 was admitted with diagnoses including chronic obstructive pulmonary disease (COPD) and emphysema and had a care plan that required regular maintenance of the oxygen concentrator. Despite this, multiple observations on consecutive days showed that the filter was not cleaned. The Dementia Unit Manager confirmed that the filter did not appear to have been cleaned during the previous third shift as indicated on the MAR. Similarly, R119, who was admitted with acute respiratory failure with hypoxia, also had an unclean oxygen concentrator filter. Observations and interviews confirmed that the filter was covered with a thick, white substance, and the Dementia Unit Manager verified that it did not appear to have been cleaned as required. Interviews with a Certified Nursing Assistant and a Licensed Practical Nurse revealed that the responsibility for cleaning the oxygen concentrator filters lay with the nurses assigned to the residents' hall. The Director of Nursing stated that her expectation was for the third shift nurse to clean the concentrators weekly and document the activity, but all nursing staff were responsible for ensuring the equipment was clean and free of debris. Despite these expectations, the observations and interviews indicated a failure to adhere to the facility's policy, leading to the deficiency in maintaining clean oxygen concentrator filters for the residents involved.
Latest citations in Georgia
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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