Bonterra Transitional Care & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in East Point, Georgia.
- Location
- 2801 Felton Drive, East Point, Georgia 30344
- CMS Provider Number
- 115555
- Inspections on file
- 17
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Bonterra Transitional Care & Rehabilitation during CMS and state inspections, most recent first.
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 severe dysphagia and cognitive impairment, who required a pureed diet with thin liquids, was given a sandwich by a CNA, contrary to their care plan and physician orders. The resident choked, required emergency intervention, was hospitalized, transferred to hospice, and later died. The facility failed to implement the care plan and provide the prescribed diet, resulting in serious harm.
A resident with severe cognitive impairment and dysphagia, who was ordered a pureed diet, was given a sandwich by a CNA, contrary to physician orders and care plan directives. The resident subsequently choked on the food, requiring emergency intervention, and later died after being transferred to a hospice facility. Investigation confirmed neglect and policy violations related to dietary management.
A resident with an order for a mechanically altered diet was given a sandwich by a CNA, contrary to the prescribed pureed snack. This led to the resident being sent to the ER, transferred to hospice, and subsequently expiring. The Administrator and DON were aware of the incident, which was determined to be noncompliance with federal requirements for quality of care and care planning, resulting in Immediate Jeopardy.
A resident with recent lower extremity amputations experienced unmanaged pain and embedded surgical staples after the facility failed to arrange transportation for a post-op appointment. Despite care plans and physician orders for pain management, the resident's pain persisted due to missed staple removal, and staff were aware of the discomfort but did not ensure timely intervention.
A resident with recent amputation surgery and complex medical needs missed a scheduled staple removal appointment because the facility failed to arrange transportation. The appointment was rescheduled and canceled without notifying the family, and the resident experienced pain and embedded staples as a result. Staff interviews and record reviews confirmed lapses in communication and transportation coordination.
The facility did not maintain an effective Antibiotic Stewardship program, as evidenced by missing lab orders, unresolved antibiotic stop dates, lack of documentation on antibiotic duration, and inadequate monitoring of residents with infections, especially those admitted or transferred from hospitals. The IP Nurse confirmed that lab follow-up and infection tracking were not consistently performed, and the DON and Administrator acknowledged expectations for adherence to policy.
Handrails in two wings were repeatedly blocked by dressers due to ongoing construction, making them inaccessible for residents who require support for ambulation. Additionally, a resident with a history of dementia and substance abuse was found with multiple medications at bedside without a physician's order or an assessment for self-administration, contrary to facility policy. The DON and Administrator confirmed both deficiencies.
Multiple medication carts were observed left unlocked and unattended by staff, including LPNs and a CMA, despite facility policy and recent in-service training requiring carts to be locked when not in use. Staff confirmed the presence of various medications, including narcotics, in the unsecured carts and acknowledged the expectation to keep carts locked at all times.
Staff prepared pureed food without following a formal recipe, instead relying on personal experience to determine ingredient amounts and consistency. The Dietary Kitchen Manager confirmed that no current recipe was used, and the Administrator stated that recipes should be followed to ensure proper consistency. This practice had the potential to affect six residents on a pureed diet.
Surveyors found that staff failed to properly label and date opened food items in the pantry and cooler, did not adequately cover or seal some foods, and did not maintain the ice machine free of debris. These actions were inconsistent with facility policies and had the potential to affect all residents receiving food orally.
The facility did not maintain proper infection surveillance and monitoring, with missing documentation, incomplete tracking, and absent infection criteria in the Infection Control Book. Additionally, personal clothing was improperly stored on a linen cart, and clean laundry was transported uncovered in hallways, contrary to infection control protocols.
The facility did not provide effective behavioral health training aligned with its facility assessment, as evidenced by multiple staff interviews and record reviews showing a lack of education on schizophrenia, mental disorders, and PTSD. Several residents with these diagnoses had care plans addressing complex behavioral needs, but staff—including CNAs, LPNs, RNs, agency staff, and non-clinical personnel—reported little or no training on these conditions. Training records and orientation materials lacked content specific to behavioral health, and agency staff and volunteers did not receive documented instruction on these topics.
A resident who is cognitively intact and dependent on staff for ADLs was provided personal care with the door to her room left open, despite facility policy requiring privacy during such care. Staff and the DON confirmed that the door should have been closed, and the resident reported the incident herself, indicating a failure to maintain dignity and privacy.
A resident room was observed with brown stains on the wall, identified as feces thrown by a roommate, which remained uncleaned over several days. Housekeeping staff did not address the stains despite facility policy requiring cleaning of visibly soiled surfaces, and both the Housekeeping Director and Administrator confirmed that walls are expected to be kept clean and sanitary.
A resident with significant pain management needs was prescribed oxycodone, but the facility failed to maintain accurate records and secure the medication, resulting in missing doses and unaccounted pills. Staff provided inconsistent documentation and statements, and the required controlled drug sheet was missing, leading to the misappropriation of the resident's prescribed narcotics.
A resident admitted with a prescription for oxycodone experienced a discrepancy in the number of pills received and administered, with all medication reportedly gone within three days and missing documentation. Despite facility policy and staff acknowledgment that such incidents are reportable, the suspected misappropriation of narcotics was not reported to the State Survey Agency.
The facility did not obtain Level II PASARR screenings for two residents with mental health diagnoses, including schizoaffective disorder and PTSD, despite clear indications in their records and care plans. Staff interviews revealed a lack of awareness about which conditions require Level II PASARR, resulting in non-compliance with facility policy and federal requirements.
A resident with moderate cognitive impairment and dependence on staff for personal hygiene did not receive proper nail care, despite requesting assistance and not refusing the service. Staff and observations confirmed the resident's fingernails remained long and unclean, contrary to facility policy and care expectations.
Two residents receiving oxygen therapy were not administered oxygen at the rates ordered by their physicians. One resident with COPD and respiratory failure received higher oxygen flow rates than prescribed, while another resident with pulmonary embolism and emphysema also received oxygen at a higher rate than ordered. Staff interviews confirmed that nursing staff are responsible for verifying and setting the correct oxygen rates, but this was not consistently done.
A resident with moderate cognitive impairment and significant oral pain due to a loose tooth did not receive timely dental services, despite repeated assessments noting the issue and daily reports of pain to nursing staff. The required referral process was not completed, and the resident was not referred to the in-house dental program, even though they qualified for Medicaid dental benefits. Staff interviews confirmed breakdowns in communication and failure to follow the facility's dental services policy.
A resident with severe cognitive impairment and dependence on staff for ADLs was left without a functional call system after a nurse repeatedly told the resident not to use the call device and the call system cord was found unplugged. Facility policy required call lights to be accessible and answered promptly, and the DON confirmed staff should not instruct residents not to use the call device.
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 Follow Care Plan Results in Resident Choking and Death
Penalty
Summary
A deficiency occurred when a resident with a history of dysphagia following cerebral infarction, oropharyngeal phase dysphagia, cerebrovascular disease, adult failure to thrive, and severe cognitive impairment was not provided care in accordance with their comprehensive care plan. The resident's care plan and physician orders specified a mechanically altered, pureed diet with thin liquids due to their swallowing difficulties and risk of choking. Despite these documented dietary restrictions, the resident was given a sandwich by a Certified Nursing Assistant (CNA), which was not consistent with the prescribed diet. The incident was observed when the resident, while sitting in a wheelchair at the nursing station, began choking on undigested food. Food was seen falling from the resident's mouth, and the resident was struggling to breathe. Immediate interventions, including the Heimlich maneuver and a mouth sweep, were attempted by an LPN but were unsuccessful. Cardiopulmonary resuscitation (CPR) was initiated, and emergency services were called. The resident eventually started breathing again and was transported to the hospital by EMS. Following the event, it was determined that the resident was admitted to a hospice facility after hospital discharge and subsequently expired. The facility's failure to implement the resident's care plan and provide the appropriate diet as ordered directly led to the choking incident and the resident's transfer to the hospital, hospice admission, and eventual death. The survey identified this as noncompliance with federal requirements for comprehensive care planning and quality of care.
Removal Plan
- The facility's Modified Texture of Food Policy, Care Plan Policy, and Resident Food Preferences Policy were reviewed and staff in-service education was initiated. All policies were reviewed with 100% staff except those on Leave of Absence and Family Medical Leave Act.
- An Ad Hoc QAPI meeting was held with key facility leadership and staff to review the IJ Removal Plan. The Care Plan policy was reviewed with no changes. A Daily Diet Verification Audit was performed for 100% of current residents to ensure meal tray cards matched diet orders, Kardex, and care plans.
- No staff worked until they had completed the in-service education. Part-time, PRN, and contracted staff will be in-serviced and educated on the relevant policies before being allowed to work.
- All newly hired staff will be in-serviced on their first day of hire during orientation, annually, and quarterly. Individuals will not work until they have received this in-service/training. All residents' care plans were reviewed and updated to reflect appropriate diet orders.
- The facility implemented interventions to minimize environmental risks and hazards, including Daily Diet Verification Audit, Snack Distribution Audit, and Meal Tray Observation Audit for 100% of current residents. Education was provided to all staff regarding relevant policies and reporting procedures.
- New interventions will be monitored by the DON for effectiveness using audit tools. If a problem is identified, it will be addressed by the Food Service Director, Administrator, DON, and Medical Director, with possible Ad Hoc QAPI meetings and corrective action if necessary.
Failure to Provide Prescribed Pureed Diet Results in Resident Choking and Death
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of dysphagia, oropharyngeal phase, was not provided with the prescribed pureed diet. The resident was admitted with multiple diagnoses, including dysphagia following cerebral infarction, cerebrovascular disease, adult failure to thrive, and required supervision or assistance with eating. Physician orders and the care plan specified a no added salt (NAS), pureed/dysphagia puree texture, and thin liquids consistency diet. Despite these orders, the resident was given a sandwich by a Certified Nursing Assistant (CNA), as confirmed by camera footage and staff interviews. The facility's policies required careful reading of tray cards to ensure correct food textures were served, and the risks and benefits of specialized diets were to be communicated by the physician and dietician. On the day of the incident, the resident was observed pointing to a snack tray, after which the CNA handed him a sandwich. Shortly after, the resident was found choking on undigested food at the nurse's station, with food falling from his mouth and difficulty breathing. Staff attempted the Heimlich maneuver and a mouth sweep, but initial efforts were unsuccessful. Emergency services were called, and CPR was performed until the resident was transported to the emergency room. Subsequent investigation substantiated the allegation of neglect, and the CNA involved was terminated. The resident was later transferred to a hospice facility, where he expired. The facility's failure to follow prescribed diet orders and care plan interventions directly led to the resident receiving an inappropriate food item, resulting in a choking incident and subsequent death.
Removal Plan
- Review and update the facility's Modified Texture of Food Policy, Care Plan Policy, and Resident Food Preferences Policy; initiate staff in-service education on these policies.
- Hold an AdHoc QAPI meeting with key facility leadership to review the IJ Removal Plan and Care Plan policy.
- Perform a Diet Verification Audit for 100% of current residents to ensure meal tray cards match diet orders, Kardex, and care plans.
- Provide in-service education to all staff, including administrative, nursing, dietary, housekeeping, maintenance, and activities staff, on relevant policies.
- Require that no staff work until they have completed the in-service education; ensure all part-time, PRN, and contracted staff are educated before working.
- Implement a process for all newly hired staff to be in-serviced during orientation, with annual and quarterly retraining.
- Review and update all residents' diet orders and care plans to ensure accuracy.
- Implement environmental interventions including Diet Verification Audit, Snack Distribution Audit, and Meal Tray Observation Audit for all residents.
- Educate all staff on reporting unmatched meal trays and diet orders to the Food Service Director and Director of Nursing.
- Report all audit findings to the QAPI Committee and conduct an Ad Hoc QAPI meeting.
- Monitor new interventions for effectiveness using audit tools; address identified problems with the Food Service Director, Administrator, DON, and Medical Director.
- Establish a process for meetings with all relevant parties if a policy violation occurs, with escalation to Ad Hoc QAPI meeting and corrective action if needed.
- Validate completion of all corrective actions and removal of Immediate Jeopardy status.
Failure to Follow Care Plan for Mechanically Altered Diet Results in Resident Death
Penalty
Summary
The facility failed to implement and follow the care plan for a resident who was ordered to receive a mechanically altered diet. Despite the resident's dietary restrictions, a Certified Nursing Assistant (CNA) provided the resident with a sandwich, which was not consistent with the prescribed pureed snack. This action was observed by the Administrator through facility camera footage. As a result of receiving the inappropriate food item, the resident was sent to the local emergency room and subsequently transferred to a hospice facility, where the resident expired. The incident was recognized as a failure to comply with federal regulatory requirements related to quality of care and comprehensive care planning for residents with altered diets. The Administrator and Director of Nursing were aware of the incident and acknowledged that the resident's care plan was not followed. The facility's noncompliance was determined to have caused or had the likelihood to cause serious injury, harm, impairment, or death to residents, leading to the identification of Immediate Jeopardy for multiple federal regulations.
Removal Plan
- An Ad Hoc Quality Performance Improvement (QAPI) meeting was held with the Administrator, Social Services Director (SSD), the DON, Corporate Operations Consultant (COC), and Food Service Director (FSD) to identify the root cause of failure to follow R165's care plan. The facility's Modified Texture of Food Policy, Care Plan Policy, and Resident Food Preferences Policy were reviewed; no changes were made.
- The Administrator's job description was reviewed with the Administrator, FSD, SSD, and DON by the COC. No revisions were made.
- The COC in-serviced the Administrator, DON, FSD, and SSD on how to implement a process on how to verify diet orders before distributing resident meal trays, how to track and trend to determine a root cause analysis, and communication among departments on reviewing and updating resident care plans timely. The facility's QAPI policy was reviewed specifically regarding how to determine root cause analysis (RCA).
- The COC reviewed and approved the facility's audit forms and Plan of Correction (PoC) for any further areas of concern. Name of Audits- Daily Diet Verification Audit and Snack Distribution Audit. Residents' diets and care plans were discussed with the Administrator, DON, and FSD. Interventions were put into place, such as removing accessible snacks from the nurse stations; snacks were placed inside the pantry and available upon request. A snack diet reference sheet was initiated and placed inside the pantry.
- The Corporate Nurse Consultant (CNC) and DON audited the resident's diet orders and meal tray cards. The audits are named Daily Diet Verification Audit and Snack Distribution Audit. The Administrator, DON, and FSD will discuss all diet order changes in the morning and the clinical meeting to ensure all care plans are updated and accurate. Documentation will be monitored through the Abuse Performance Improvement Plan (PIP) and reported during QAPI by the DON and Administrator. The SSA reviewed and compared Diet Master from the Dietary Department and the Facility's Diet Type Report for all residents in the facility; no discrepancies were found.
- The COC met with the Administrator and DON to review the process of providing direct oversight of the following correct processes in the building as it relates to following care plans for resident diet orders. There is ongoing educational training for all members of the facility through the company's online courses. The Administrator was also in-service on how to conduct a QAPI meeting and how to identify and complete an RCA by the COC. The SSA reviewed in-service education related to the QAPI meeting and RCA with no concerns.
- The corrective actions were completed, and the facility alleges that the immediate jeopardy was removed. All corrective actions were completed. The facility's IJ was determined to be Past Noncompliance, removed.
Failure to Provide Timely Pain Management and Post-Op Care
Penalty
Summary
A deficiency occurred when the facility failed to provide safe and appropriate pain management for a resident following a recent surgical amputation. The resident, who had a history of bilateral lower extremity amputations, diabetes, and other complications, was admitted with orders for pain management and wound care. The care plan included monitoring and documenting pain, as well as interventions for wound management. Despite these plans, the facility did not ensure the resident attended a scheduled post-operative appointment for staple removal due to a failure to arrange transportation. As a result of the missed appointment, the resident experienced ongoing pain and discomfort, with staples remaining in the surgical site. The wound care nurse attempted to remove the staples at the facility after obtaining a verbal order from the vascular clinic, but was unable to remove the last six staples due to the resident's pain. Observations revealed that these remaining staples became embedded in the skin, with crust build-up, and the resident reported persistent pain and concern about possible infection. Staff interviews confirmed that the resident frequently expressed pain related to the embedded staples. The medical director was not initially aware that the resident had missed the post-op appointment or that the staples remained in place, and pain assessments were not effectively communicated to the physician. The facility's policy required ongoing pain recognition and management, but the failure to provide transportation and ensure timely removal of surgical staples resulted in actual harm to the resident, as evidenced by embedded staples and unmanaged pain.
Failure to Arrange Transportation Results in Missed Post-Op Appointment and Harm
Penalty
Summary
The facility failed to arrange transportation for a resident to attend a post-operative medical appointment, resulting in the resident missing a scheduled staple removal following an amputation surgery. The resident, who had a history of major orthopedic surgery, bilateral lower extremity impairment, and pain management needs, was admitted with multiple complex diagnoses including diabetes, atherosclerosis, and surgical site complications. Documentation showed that the resident's appointment was rescheduled without notifying the family, and ultimately canceled due to transportation not being arranged by the facility. The family was not informed of the changes, and the resident reported that transportation was never scheduled. Interviews with staff and review of records revealed that the unit clerk responsible for transportation coordination was aware of the appointment but did not ensure transportation was arranged. The resident experienced pain and reported tightness around the surgical staples, which became embedded due to the missed appointment. The facility did not provide requested documentation of appointment and transportation forms, and the Director of Nursing confirmed that a log should be maintained to track appointments and transportation, which was not effectively done in this case.
Failure to Maintain Antibiotic Stewardship Program
Penalty
Summary
The facility failed to establish and maintain an effective Antibiotic Stewardship program as required by its own policy. Observations and record reviews revealed missing laboratory orders, unresolved dates for antibiotics, lack of documentation on the duration of antibiotic therapy, and inadequate monitoring of residents with infections, particularly those admitted or transferred from hospitals. The Infection Control Book did not contain necessary information to determine true infections, and there was no consistent follow-up on laboratory results or tracking of clinical signs and symptoms related to infections. Interviews with the Infection Preventionist (IP) Nurse confirmed that she did not routinely perform lab follow-up or document resolved dates for antibiotics, and that infections among newly admitted residents were not being tracked or monitored. The Director of Nursing (DON) acknowledged that the IP Nurse was expected to submit weekly listings and follow the facility's policy, and confirmed that missing information could increase the risk of infections not being treated appropriately. The Administrator stated that the DON oversees the Infection Control Program and expected the IP Nurse to adhere to facility policy.
Handrails Blocked by Furniture and Failure to Assess Self-Administration of Medication
Penalty
Summary
Surveyors observed that handrails in both the East Wing and another named wing were repeatedly blocked by dressers, making them inaccessible to residents. These obstructions were noted on multiple occasions over several days, with varying numbers of dressers placed between or beside rooms, directly impeding access to the handrails. Interviews with the Maintenance Director revealed that the obstructions were due to ongoing construction and remodeling of closets, with new wardrobes being delivered and temporarily stored in the hallways. Both the DON and the Administrator confirmed that the handrails were blocked and acknowledged that this interfered with residents' ability to use them for mobility support. Additionally, a deficiency was identified regarding the facility's failure to adequately assess a resident for self-administration of medication. One resident was observed with multiple medications, including triamcinolone acetonide ointment, nystop powder, and milk of magnesia, stored on his nightstand over several days. The resident reported receiving the medications from the hospital and using them regularly for skin issues. However, a review of the electronic medical record showed no physician orders for these medications and no assessment for the resident's ability to self-administer them. The facility's policies require that residents be assessed by the interdisciplinary team and have a physician's order before being allowed to self-administer medications. The DON confirmed that no such assessment or order was present for the resident in question and that staff are expected to monitor for and report medications found in residents' rooms. The lack of assessment and oversight resulted in the resident having access to and using medications without proper authorization or evaluation.
Medication Carts Left Unlocked and Unattended
Penalty
Summary
Staff failed to properly lock and secure three of four medication carts, as required by facility policy and professional standards. Observations revealed that medication carts on the East Wing and [NAME] Wing were left unlocked and unattended while residents were present in the vicinity. In one instance, an LPN left a medication cart unlocked outside the nurse station while she sat behind the station working on a computer, confirming that the cart contained various medications, including psychotropics, diuretics, and narcotics. Another medication cart was left unlocked for 10-15 minutes by a CMA, who was away from the cart and working at the nurse station. Additional observations showed that medication carts were left unlocked and unattended by other staff, including an LPN who left the cart while attempting to access a computer and another LPN who left the cart unlocked while in a resident's room. Interviews with staff and supervisors confirmed awareness of the policy requiring medication carts to be locked at all times when unattended. Staff acknowledged recent in-service training on medication cart security and recognized the potential for residents, staff, or family members to access unsecured medications. Supervisory staff reiterated the expectation that medication carts remain locked when not in direct view of staff, regardless of the duration of absence. Despite this, multiple instances of non-compliance with the policy were observed and confirmed by staff.
Failure to Use Recipe for Pureed Diet Preparation
Penalty
Summary
The facility failed to use a formal recipe when preparing pureed food for residents requiring a pureed diet. During an observation, a food service staff member was seen preparing pureed carrots without referencing a recipe, instead relying on her own experience to determine the amount of carrots and broth to use. The staff member adjusted serving sizes and ingredient amounts without measurement, and added broth by sight rather than by a measured amount. When questioned, she acknowledged that she should be measuring the broth and using a recipe, but did not do so during the observed preparation. The recipe she later produced did not match the number of servings or ingredients used in the preparation. The Dietary Kitchen Manager confirmed that no recipe was followed and that the recipe provided was outdated and not in use, as the facility had changed its menu system and no longer used thickeners. The DKM also acknowledged that not following a recipe could result in incorrect food consistency, which may cause harm to residents. The Administrator stated that kitchen staff are expected to follow recipes to ensure the correct consistency when preparing pureed foods. This deficiency had the potential to affect six residents on a pureed diet.
Deficient Food Storage, Labeling, and Ice Machine Sanitation
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's food storage and handling practices. During observations with the Dietary Manager (DM), several opened food items in the pantry, such as vinegar, peanut butter, quick oats, and creamy wheat, were found without expiration dates. In the cooler, bags of cut cabbage, carrots, spinach, and hot dogs were either not labeled with expiration dates or not labeled at all, with the spinach also noted as wilted. In the freezer, a bag of green peas was not properly sealed. These findings were inconsistent with the facility's policies, which require all food items to be labeled, dated, and properly stored to prevent cross-contamination. Additionally, the ice machine was found to contain debris during an observation and interview with the DM, who stated that the machine is typically cleaned monthly. The Maintenance Director confirmed responsibility for cleaning the ice machine and acknowledged the presence of debris after being shown a photo. Interviews with the DM and Administrator confirmed that staff are expected to label and date food items and that the Maintenance Director is responsible for cleaning the ice machine according to the established schedule. These lapses in following established policies had the potential to affect all residents receiving food orally.
Deficient Infection Surveillance and Improper Laundry Handling
Penalty
Summary
The facility failed to provide proper surveillance and monitoring for infections and communicable diseases for all 114 residents. Review of the Infection Prevention and Control Program policy revealed requirements for ongoing monitoring, documentation, and reporting of infections, but the facility's Infection Control Book was missing infection criteria sheets, accurate data collection, color-coded infection tracking on facility maps, and surveillance records for two months. The Infection Preventionist (IP) Nurse confirmed these deficiencies, acknowledging missing documentation and incomplete monitoring and tracking. The DON and Administrator both stated that the IP Nurse was expected to follow policy and complete the infection control process without missing items, and confirmed that the lack of information could increase the risk of infections not being treated accordingly. Additional observations included improper handling of residents' personal clothing and laundry. A resident's personal clothing was found stored on a unit linen cart, which the Assistant DON confirmed was inappropriate. Furthermore, a Laundry Aide was observed transporting an uncovered laundry cart with clean clothing exposed in the hallways, contrary to infection control practices. The IP Nurse confirmed that clean clothing should be covered during transport and that the housekeeping department was expected to comply with infection control protocols.
Failure to Provide Behavioral Health Training Consistent with Facility Assessment
Penalty
Summary
The facility failed to provide an effective behavioral health training program consistent with its facility assessment and person-centered care requirements. The deficiency was identified through observations, staff and resident interviews, record reviews, and a review of the facility's policy on education and training requirements. The policy stated that training should be based on the needs identified in the facility resource assessment, but evidence showed that staff did not receive adequate training on behavioral health topics relevant to the resident population, including schizophrenia, mental disorders, and PTSD. Three residents with significant behavioral health needs were reviewed. One resident had diagnoses including cerebrovascular disease and schizoaffective disorder/bipolar type, with care plans addressing screaming and verbal outbursts. Another resident had schizophrenia and exhibited verbal aggression, accusations, and suicidal behavior, with care plans and physician orders reflecting these issues. A third resident had mood disorder, PTSD, and cognitive decline, with care plans noting delusions, negative self-feelings, and resistance to care. The facility assessment confirmed that mental disorders, schizophrenia, and PTSD were common diagnoses among residents. Despite these needs, training records revealed only one in-service on managing crisis behaviors and one on behavior management in the past year, with little or no content specific to schizophrenia, mental disorders, or PTSD. Orientation materials for CNAs and other non-nursing staff did not include behavioral health topics. Interviews with CNAs, LPNs, RNs, agency staff, housekeeping, dietary, activities, and other staff consistently revealed a lack of training on behavioral health, schizophrenia, mental disorders, and PTSD. Agency staff and volunteers also did not receive documented behavioral health training. The staff development coordinator and social services director confirmed that training on these topics was infrequent or outdated, and that agency staff were expected to self-educate using binders that lacked relevant materials.
Failure to Maintain Resident Privacy During Personal Care
Penalty
Summary
Staff failed to maintain a resident's dignity and privacy during the provision of personal care. The facility's policy requires that all residents be treated with dignity and respect, and that privacy be maintained by closing the door and pulling the privacy curtain during care. A cognitively intact resident with hemiplegia and significant dependence on staff for activities of daily living, including toileting and bathing, was observed receiving peri-care and assistance with changing while the door to her room was left open. Staff interviews confirmed that the door should have been closed during these activities, and both CNAs involved acknowledged the expectation to maintain privacy by closing the door and pulling the curtain, especially since the resident has a roommate who could enter at any time. The resident herself reported that staff left the door open while providing a bed bath. The Director of Nursing also confirmed that the facility's expectation is for the door to be closed and the privacy curtain pulled during personal care. These actions and inactions resulted in a failure to provide care in a manner that maintained or enhanced the resident's dignity, as required by facility policy and resident rights regulations.
Failure to Maintain Clean and Homelike Resident Room Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment in one resident room located on the East Wing. Facility policy required that walls, blinds, and window curtains be cleaned when visibly soiled, and that staff spot clean walls daily. During observations, brown stains were noted on the wall to the left of the entrance in the identified room. A resident in the room reported that the stains were feces thrown by his roommate and that they had been present for some time. Subsequent observations confirmed that the stains remained on the wall over multiple days. Interviews with housekeeping staff revealed that the assigned aide did not notice or clean the stains, despite her responsibilities including cleaning walls and edges of rooms. The Housekeeping Director confirmed that staff are expected to clean any spots found on the walls. The Administrator also stated that her expectation is for resident walls to be maintained in a clean and sanitary condition. The failure to address the visibly soiled wall resulted in the room not being maintained in accordance with facility policy and resident rights.
Failure to Prevent Misappropriation of Prescribed Narcotics
Penalty
Summary
The facility failed to protect a resident from misappropriation of prescribed narcotics, specifically oxycodone, as required by its Abuse Prevention and Drug Diversion policies. The resident, who was cognitively intact and had significant medical needs including recent amputations and pain management requirements, was prescribed 15 tablets of oxycodone to be administered as needed. Documentation revealed inconsistencies in the administration and accounting of the medication, with only a few doses recorded as given and the remainder unaccounted for. The controlled drug sheet for the medication was missing, and the facility was unable to provide a clear record of the medication's administration or disposition. Interviews with staff and review of records indicated that the required procedures for handling, documenting, and reconciling controlled substances were not followed. Several LPNs provided conflicting or incomplete statements regarding the administration of the medication, and some staff were asked to write statements after the fact, sometimes without clear recollection or supporting documentation. The DON confirmed the absence of the controlled drug sheet and was unable to account for the remaining medication. The pharmacy also reported discrepancies in the order and delivery of the medication. The resident and her family expressed concerns about the missing medication, with the family stating that all 15 pills were gone within three days and doubting that the resident had received all doses. The resident herself recalled taking only three pills and was not informed about the dosing schedule or when the medication would run out. The facility's failure to maintain accurate records, secure the medication, and follow established protocols resulted in the misappropriation of the resident's prescribed narcotics.
Failure to Report Suspected Misappropriation of Narcotics
Penalty
Summary
The facility failed to report a suspected misappropriation of prescription narcotics for one resident to the State Survey Agency (SSA) as required by policy and regulation. The resident, who was cognitively intact and had a history of major orthopedic surgery and pain management needs, was admitted with a hospital discharge order for oxycodone. Documentation showed discrepancies between the number of oxycodone tablets received and administered, with the resident and her family reporting that all 15 pills were gone within three days, despite the resident recalling only taking three pills. The facility was unable to produce the controlled drug sheet for the medication, and the DON confirmed the medication was not in her possession or in the locked box. Interviews with staff, the DON, and the Medical Director revealed a lack of clear documentation and communication regarding the administration and disposition of the narcotic medication. The DON and Administrator both acknowledged that misappropriation of property related to narcotics is a reportable offense, yet the incident was not reported to the SSA. The facility's own policies required investigation and reporting of such incidents, but these procedures were not followed in this case.
Failure to Complete Required PASARR Level II Screenings for Residents with Mental Disorders
Penalty
Summary
The facility failed to obtain a Level II PASARR screening for two residents with mental disorders or intellectual disabilities, as required by its own policy and federal regulations. For one resident, the electronic medical record showed diagnoses including schizoaffective disorder, bipolar type, and a care plan addressing cognitive impairment and behavioral symptoms such as screaming and cursing. This resident was dependent on staff for all ADLs and was prescribed psychotropic medications. Despite these indicators, there was no evidence of a completed Level II PASARR screening prior to or after admission. For the second resident, the record indicated diagnoses of mood disorder due to a physiological condition with mixed features and PTSD, with care plans addressing negative feelings, cognitive decline, and problematic behaviors such as yelling and resistance to care. The social worker and DON both confirmed that a Level II PASARR screening had not been completed for this resident, with the social worker stating she was unaware that PTSD qualified for such screening. Interviews with staff revealed a lack of understanding regarding which diagnoses require a Level II PASARR, and the facility's process did not ensure compliance with its policy or regulatory requirements.
Failure to Provide Required Nail Care for Dependent Resident
Penalty
Summary
Staff failed to provide adequate nail care for a resident who was dependent on staff for personal hygiene due to moderate cognitive impairment and medical conditions including a recent heart attack and metabolic encephalopathy. The facility's policy required staff to supervise and assist with ADLs, including cleaning and trimming nails as needed. The resident's care plan noted a preference for refusing some ADL care, but the resident specifically stated he did not refuse nail care and had requested staff assistance to cut his fingernails. Despite this, observations on multiple occasions revealed the resident's fingernails were long, curled, and had a dark substance underneath. Interviews with staff confirmed awareness of the resident's long nails and the presence of debris, with one CNA stating that nail care should be performed every two weeks and acknowledging the resident's nails had not been properly maintained. The DON stated the resident was care planned for refusals but also confirmed that ADLs, including nail care, should be attempted daily if the resident allows. The failure to provide necessary nail care occurred despite the resident's requests and lack of refusal, resulting in the deficiency.
Failure to Administer Oxygen Therapy per Physician Orders
Penalty
Summary
Staff failed to administer oxygen therapy according to physician orders for two residents receiving oxygen therapy. One resident with chronic obstructive pulmonary disease, atelectasis, and respiratory failure with hypoxia was ordered to receive oxygen at 3 liters per nasal cannula continuously. However, observations showed the oxygen concentrator was set at 4.5 liters and later at 5 liters, exceeding the prescribed rate. The resident was cognitively intact and had a care plan specifying continuous oxygen as ordered by the physician. Another resident with pulmonary embolism and emphysema, who had severe cognitive impairment, was ordered to receive oxygen at 3 liters per mask or cannula continuously. Observations revealed the oxygen concentrator was set at 5 liters, higher than the ordered rate. Multiple staff interviews confirmed that nursing staff are responsible for checking physician orders and ensuring the oxygen concentrator is set to the correct rate, but this was not done for these residents.
Failure to Provide Timely Dental Services for Resident with Oral Pain
Penalty
Summary
The facility failed to provide necessary dental services for one resident who was identified as having a loose tooth and experiencing significant oral pain. According to the facility's Dental Services Policy, routine and emergency dental services should be available based on resident assessments and care plans, with annual and as-needed dental assessments. The resident in question was admitted with hemiplegia and hemiparesis, had moderate cognitive impairment, and required assistance with oral hygiene. The care plan and physician's orders indicated the need for dental evaluation and treatment as indicated. Despite these documented needs, the resident's oral assessments repeatedly noted a loose tooth, but the section indicating whether a referral to a dentist was needed was left blank. The resident reported daily to nursing staff about severe tooth pain and the need for extraction, but no referral was made. Multiple interviews with staff confirmed that the process for dental referrals was not followed: the nurse did not complete the referral section of the assessment, and the Social Services Director was not notified of the need for a dental consult. The resident continued to experience pain and had not seen a dentist since admission. Staff interviews revealed a lack of awareness and communication regarding the resident's dental needs. CNAs reported oral concerns to nurses, but the nurses did not act on the information by initiating a referral. The Social Services Director and unit manager confirmed that the resident qualified for Medicaid dental benefits and should have been referred to the in-house dental program, but this did not occur. The Director of Nursing and Administrator acknowledged that the failure to make a timely dental referral could result in negative outcomes, and confirmed that the required process for dental referrals was not followed for this resident.
Failure to Ensure Accessible and Functional Call System for Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of falls was not provided with a functional and accessible call system in their room. During an observation, a registered nurse repeatedly instructed the resident not to use the call device, stating that the resident was pressing it frequently for a snack. The nurse was observed leaving the room after making these statements. The call system cord was later found extracted from the wall, rendering it nonfunctional. Interviews with the resident's roommates confirmed that the nurse had told the resident to stop pressing the call light. The nurse acknowledged that staff are not supposed to keep the call device away from the resident but explained her actions by stating the resident had already received a snack. The resident's medical record indicated severe cognitive impairment, dependence on staff for activities of daily living, and a care plan that encouraged the use of the call bell for assistance. Facility policy required that call lights be answered promptly and remain accessible to residents. The Director of Nursing confirmed that all call lights should remain in place and that staff should not instruct residents not to use the call device. The failure to ensure the call system was accessible and functional for this resident constituted a deficiency.
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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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