Bryan County Hlth & Rehab Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Richmond Hill, Georgia.
- Location
- 127 Carter St, Richmond Hill, Georgia 31324
- CMS Provider Number
- 115621
- Inspections on file
- 16
- Latest survey
- April 1, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Bryan County Hlth & Rehab Ctr during CMS and state inspections, most recent first.
Pureed meals were prepared without standardized recipes or measuring tools for residents on texture-modified diets. A Dietary Aide made pureed carrots with carrots and water and pureed chicken and dumplings with chicken and dumplings, cream of chicken soup, and water, while stating she did not use a recipe. The CDM confirmed the recipe was not used and that the facility did not have a recipe for chicken and dumplings, and the DON said she was unaware dietary staff were not using recipes.
Improper Food Labeling, Dating, and Kitchen Equipment Cleanliness: Surveyors found unlabeled bread and buns, multiple expired containers of Roasted Beef Base, cheese without a use-by date, and a container of French Vanilla Alamera past its use-by date. The kitchen can opener also had a greasy, black substance. The CDM and DON confirmed the findings and stated that dietary staff were expected to properly label, date, and discard out-of-date food items.
Dumpster Area Not Kept Closed or Free of Debris: The facility failed to keep the outdoor dumpster area sanitary per its Outside Dumpster Policy. Surveyors observed wooden pallets behind the dumpsters, with two dumpster lids and one side door open; the DM confirmed the conditions and said maintenance was responsible for removing the pallets. Follow-up observations showed the side door remained open and the pallets were still present, and the DON stated she was unaware of the conditions.
Failure to Feed Residents at Eye Level: Four residents with severe cognitive impairment and dependent eating status were observed being fed while staff stood rather than sitting at eye level. The residents had diagnoses including Alzheimer’s disease, dysphagia, aphasia, dementia, and Down syndrome, and their care plans directed staff to assist with meals and oral care. Staff interviews confirmed the standing feeding practice, while later interviews with an LPN, ADON, and DON stated that staff are to sit next to residents at eye level.
A resident with severe cognitive impairment and dementia was found at the bedside with about eight pills after an LPN had given morning meds. The resident said she was taking them by herself and was unsure whether she had an order to self-administer. The record showed no physician order or assessment for self-administration, and the ADON, DON, and LPN confirmed the resident should not have been left with medication unsupervised.
A resident with hypothyroidism was given levothyroxine after breakfast even though the order and label indicated it should be given on an empty stomach before breakfast. In a separate event, an LPN crushed all of another resident's gastrostomy tube medications together and administered them as one mixture, which clogged the tube; the consultant pharmacist and DON confirmed tube medications should be crushed and given separately.
Expired and improperly dated medications were found in one medication room during an observation with the ADON. Items included expired povidone-iodine swab sticks, mineral oil enemas, Prostate, and fiber laxative, plus a tuberculin vial in the refrigerator without an open date or expiration date. The ADON also confirmed a resident’s Levemir FlexPen had passed the manufacturer expiration date, and the DON stated medications should not be expired in the medication room or medication carts.
A resident with moderate cognitive impairment and a history of acute kidney failure did not have all required skin assessments and topical treatments properly documented. Although LPNs reported completing the assessments and administering prescribed steroid cream for a skin condition, they failed to consistently record these actions in the medical record and treatment administration records, resulting in incomplete and inaccurate documentation.
Surveyors found that opened food items in the kitchen freezer, such as pork sausages, chicken breasts, and French fries, were not labeled or dated as required by facility policy. Staff interviews confirmed that all kitchen staff are responsible for labeling opened food, and the lack of labeling had the potential to affect all residents on an oral diet.
Staff failed to follow infection control protocols during wound care for two residents, including not re-cleaning wounds after contact with contaminated linens and not maintaining privacy. An LPN improperly handled and transported soiled PPE without gloves or proper containment, and did not sanitize hands or equipment as required. The facility also did not complete monthly infection surveillance or review infection control policies as required.
Staff failed to provide full privacy for four residents during wound care, leaving window blinds and privacy curtains open during treatments. This resulted in residents being exposed to view from outside areas and to roommates while receiving sensitive medical care. Nurses acknowledged not closing blinds or curtains, and the DON confirmed that full privacy was expected during such procedures.
Surveyors identified multiple environmental deficiencies, including missing and cracked plaster, chipped floor tile, stained privacy curtains, and a feeding pump pole with dried tube feeding formula. These issues were observed and verified by housekeeping, the Housekeeping Supervisor, the DON, and the Maintenance Director, with staff interviews revealing confusion over cleaning and repair responsibilities and a lack of timely reporting and resolution.
Staff did not develop or update care plans for two residents with specific medical interventions: one receiving oxygen therapy and another with an indwelling Foley catheter. Despite physician orders and documentation in the medical record, these interventions were not reflected in the residents' care plans, as confirmed by the MDS Coordinator and DON.
A resident with a history of cerebral infarction and diabetes mellitus did not receive wound care as ordered by the physician when an LPN omitted the use of rolled gauze during a dressing change, despite specific instructions in the medical record. The LPN stated the decision was due to concerns about the dressing coming off, and the DON confirmed that not following physician orders is considered a delay in care and neglect.
A resident with acute respiratory distress and heart failure was found with a free-standing, unsecured O2 tank behind their bed on multiple occasions. Staff interviews revealed that O2 tanks should not be stored in resident rooms, and a CNA admitted to forgetting to remove it. The DON confirmed the tank should not have been present, and the facility lacked a policy on accident hazards.
A resident with multiple diagnoses, including Parkinson's disease and hypertension, was observed receiving oxygen at 4 LPM via nasal cannula, contrary to the physician's order for 2 LPM as needed. Staff interviews confirmed the incorrect oxygen setting and revealed that the care plan did not address oxygen therapy, and daily checks of the oxygen concentrator were not consistently performed.
Pureed Meals Prepared Without Standardized Recipes
Penalty
Summary
Pureed foods for residents requiring texture-modified diets were not prepared according to standardized recipes and professional food service standards. During observation on 03/31/2026 at 10:49 AM, a Dietary Aide prepared pureed carrots using carrots and water without using a recipe or measuring tools. The same staff member prepared pureed chicken and dumplings using a can of chicken and dumplings, cream of chicken soup, and water, also without a recipe or measured amounts. The Dietary Aide stated she had been preparing pureed meals for a long time and knew how to do it without a recipe, and confirmed she did not use one during the puree process. The CDM confirmed that the Dietary Aide did not use a recipe and stated that the process was incorrect once it had already begun. The CDM also stated that seasoned workers had been doing the work for a long time and tended not to use a recipe, and confirmed the facility did not have a recipe for chicken and dumplings, which had been added to the menu for that evening's dinner. The DON stated on 04/01/2026 that she was unaware dietary staff were not using recipes and said her expectation was that all dietary staff use recipes when preparing all meals, including pureed meals, to ensure residents receive proper nutritional balance.
Improper Food Labeling, Dating, and Kitchen Equipment Cleanliness
Penalty
Summary
The facility failed to ensure that foods were properly labeled, dated, and discarded, and failed to ensure the cleanliness of kitchen equipment used in food preparation. During an observation tour of the kitchen with the Certified Dietary Manager (CDM), surveyors identified three loaves of raisin bread and one pack of hot dog buns without expiration dates. The refrigerator also contained five one-pound containers of Roasted Beef Base with an expiration date of May 2025, one one-pound container with an expiration date of November 2025, and one one-pound container with an expiration date of April 2025. In addition, one five-pound bag of Assorted Grated Parmesan Cheese had an open date of 01/25/2026 but no use-by date, and one metal container of French Vanilla Alamera had a use-by date of 03/06/2026. The can opener in the kitchen contained a greasy, black substance. The CDM confirmed all of the identified concerns during the observation and stated that dietary staff required re-education on proper labeling, dating, and disposal of out-of-date food items. The DON also stated that it was the facility's expectation that dietary staff properly label, date, and dispose of out-of-date food items.
Dumpster Area Not Kept Closed or Free of Debris
Penalty
Summary
The facility failed to ensure the outdoor garbage and refuse area was maintained in a sanitary manner, as required by its Outside Dumpster Policy. The policy stated that dumpster lids must remain closed after use, trash bags must not be left on the ground or outside the dumpster, only designated general trash may be disposed of in outside dumpsters, and the dumpster area must be kept free of debris. During observation on 03/30/2026 at 10:58 AM, numerous wooden pallets were seen behind the dumpsters, two of the three dumpster lids were open, and the side door of one dumpster was open. The Dietary Manager confirmed the pallets were present and stated maintenance was responsible for removing and discarding them, and also acknowledged that the dumpster lids and side door were left open at the time of observation. Follow-up observations on 03/31/2026 at 9:02 AM and 04/01/2026 at 7:56 AM showed that the side door of the trash dumpster remained open and the wooden pallets were still behind the dumpsters. During interview on 04/01/2026 at 12:43 PM, the DON stated she was unaware of the wooden pallets behind the dumpsters and unaware that the dumpster doors or lids had been left open. She stated it was her expectation that dietary and maintenance staff be re-educated on the facility's Outside Dumpster Policy.
Failure to Feed Residents at Eye Level
Penalty
Summary
The facility failed to maintain resident dignity during mealtime for four sampled residents, all of whom were dependent on staff for eating and oral hygiene and had severe cognitive impairment documented by BIMS scores of 00. The report cited the facility’s Resident Dignity & Safe Feeding Policy, which prohibited feeding while standing, rush feeding, feeding multiple residents at once, and ignoring swallowing difficulty. Each of the four residents had care plans that directed staff to assist with eating, ensure the correct diet and texture were served, and provide oral care as needed. For R7, who had diagnoses including Alzheimer’s disease, feeding difficulties, schizoaffective disorder, and dysphagia, an observation showed a Social Service DD standing while feeding the resident. For R27, who had diagnoses including acute combined systolic and diastolic heart failure, aphasia, dysphagia, and feeding difficulties, an LPN was observed standing while feeding the resident and later confirmed she was standing and stated she should sit at eye level to feed the resident. R67, who had dementia, hypertension, feeding difficulties, and a mood disorder, was observed being fed by a CNA who was standing and later confirmed she was standing while feeding the resident and stated she was supposed to sit at eye level. For R83, who had Down syndrome, epilepsy, protein C resistance, Moyamoya disease, and sleep apnea, an LPN was observed standing while feeding breakfast. The LPN confirmed she was standing and stated that she can stand or sit, but most of the time she sits to feed residents; she also stated that residents on the C Hall were different because they have dementia, so staff may sit or stand to assist with feeding. Subsequent interviews with an LPN, the ADON, and the DON stated that staff are to sit by residents at eye level to assist with feeding.
Resident Left With Bedside Medications Without Self-Administration Order
Penalty
Summary
The facility failed to ensure that a resident with severe cognitive impairment did not have access to self-administered medications. Resident R23’s record showed a BIMS score of 05, diagnoses including dementia with severe behavioral disturbances, metabolic encephalopathy, and cognitive communication deficit, and a care plan noting impaired cognition and impaired thought processes. The resident’s record also showed no physician order allowing bedside self-administration of medications and no assessment for medication self-administration. During an initial tour, R23 was observed at the bedside with approximately eight pills and stated she was taking them slowly because she did not feel well. She said the nurse had given her morning medication with water and that she was taking it by herself at the bedside, while also stating she was not supposed to take medication without supervision and was unsure whether she had an order for self-administration. The medications were removed by an LPN, and the ADON confirmed the resident had a medication cup containing eight medications at the bedside without an order for self-administration and was not to take medications unsupervised. The ADON, Administrator, and LPN all confirmed that residents do not have orders to self-administer medications and that the resident should not have been left with medication at the bedside.
Medication Timing and Tube Medication Administration Errors
Penalty
Summary
The facility failed to administer levothyroxine at the correct time for a resident with hypothyroidism, Alzheimer's disease, and atrial fibrillation. The resident's physician order was for levothyroxine sodium 50 micrograms orally once daily, and the medication label instructed administration in the morning before breakfast. During observation, the resident had already eaten breakfast when the LPN prepared to give the medication, and the medication was scheduled for 9:00 AM. The consultant pharmacist and DON both confirmed that levothyroxine should be given on an empty stomach before breakfast, and that breakfast was served earlier than the scheduled medication time. The facility also failed to crush and administer gastrostomy tube medications separately for a resident with cerebral infarction, epilepsy, gastrostomy status, and dysphagia. The care plan and physician orders required tube flushing before and after medications and with each medication, and the resident had consent for all medications to be crushed. During observation, the LPN crushed all of the resident's medications together in one pouch, mixed the crushed medications together in water, and attempted to administer them as a single mixture. The tube became clogged, and the LPN used a clog remover and repeated flushing attempts before being able to continue the medication administration and resume tube feeding. The LPN stated she knew she was not supposed to crush or administer the medications together, and the consultant pharmacist and DON confirmed that medications given through a gastrostomy tube should be crushed and administered separately.
Expired and Improperly Dated Medications in Medication Room
Penalty
Summary
The facility failed to ensure that one of two medication rooms was free of expired medications and improperly dated items. Based on observations and a concurrent interview with the ADON in the medication room for Hallways A and B, surveyors found one box of povidone-iodine swab sticks expired 09/2025, five bottles of mineral oil enemas expired 01/2025, one bottle of Prostate expired 02/12/2026, and one bottle of fiber laxative expired 02/2026. A tuberculin vial was also stored in the medication room refrigerator without an open date or expiration date, and the ADON stated she was unsure when the vial had been opened. The ADON also confirmed that a Levemir FlexPen ordered for a resident on 03/03/2024 had a manufacturer expiration date of 01/31/2026. She stated she was responsible for the medication room and explained that stock medications were arranged with the oldest items in front and newer items in back, but acknowledged that her inventory list showed stock medications would not expire until May and needed to be updated. The DON stated that medications should not be expired in the medication room or medication carts and that unit managers check and audit medication carts weekly, while the ADON is responsible for the medication room.
Incomplete Documentation of Skin Assessments and Treatments
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident with a history of acute kidney failure and moderate cognitive impairment, specifically in the area of skin condition management. The resident's care plan included interventions for monitoring skin integrity and treating a diagnosis of candidiasis, with instructions for regular skin assessments and topical medication administration. However, documentation in the electronic medical record showed that several scheduled weekly skin assessments were not recorded as completed on specific dates. Interviews with LPNs revealed that while some assessments were performed, the staff failed to document them due to being busy or forgetting. Additionally, the resident's treatment administration records for a prescribed steroid cream indicated multiple instances where there was no documentation of the treatment being administered as ordered. Several LPNs confirmed in interviews that they had provided the treatments but neglected to sign off on the treatment administration records after completion. Both the Regional Nurse Consultant and the Administrator acknowledged that all assessments and treatments should have been documented in a timely manner, but this was not consistently done.
Failure to Label and Date Opened Food Items in Kitchen
Penalty
Summary
During a kitchen tour, surveyors observed that several opened food items in the freezer, including pork sausages, chicken breasts, chicken nuggets, French fries, okra, and crispy fried onions, were not labeled or dated. Review of the facility's Food Storage policy indicated that all products should be dated to ensure proper stock rotation and adherence to the First-In, First-Out procedure. Interviews with staff confirmed that opened food items are required to have an open date and a use by date, and that all kitchen staff are responsible for labeling these items. The failure to label and date opened food had the potential to affect all residents on an oral diet.
Infection Control Deficiencies in Wound Care, PPE Handling, and Surveillance
Penalty
Summary
The facility failed to ensure proper infection control practices during wound care for two residents. In both cases, the wound care nurse did not re-clean the wound area after the residents were repositioned onto potentially contaminated linens before applying new dressings. Additionally, privacy was not maintained during wound care, as privacy curtains and window blinds were left open, exposing residents to view from outside or from roommates. The nurse acknowledged not following proper wound cleaning procedures after repositioning the residents. Another incident involved an LPN who did not follow correct procedures for handling and disposing of used personal protective equipment (PPE). The LPN transported soiled, reusable gowns in her ungloved hands and without bagging them, after removing them from the trash can, and carried them down the hall to the laundry room. The LPN also failed to sanitize hands after removing gloves and did not sanitize the treatment tray before returning it to the treatment cart. These actions were observed during wound care for a resident with a sacral wound and a Foley catheter. The facility also failed to conduct required infection surveillance activities. There was no evidence that infection control rates were calculated for three consecutive months, and the infection control policies had not been reviewed annually as required. The Infection Control Preventionist stated she was not trained to calculate infection rates and had not performed this task, and both the Administrator and DON were unaware of when the last policy review or surveillance had occurred.
Failure to Provide Privacy During Wound Care Treatments
Penalty
Summary
The facility failed to provide full privacy to four residents during wound care treatments, as observed by surveyors. In multiple instances, staff conducted wound care procedures without ensuring that window blinds were closed and privacy curtains were fully engaged. This resulted in residents being exposed to view from outside areas such as the courtyard and parking lot, as well as to their roommates, during sensitive medical treatments. The facility's own policies require that privacy be provided during such care, including the use of privacy curtains and closed blinds. For one resident with a stage four sacral pressure ulcer, the wound care nurse performed the dressing change with the privacy curtain pulled but left the window blinds open, allowing full view from the courtyard. The nurse acknowledged during an interview that she did not think to close the blinds during the procedure. Another resident with dementia and skin breakdown had wound care performed with both the privacy curtain and window blinds open, exposing the resident to their roommate and anyone outside. The nurse completed the entire treatment without providing privacy. Additional observations included a resident with a left ankle wound who received care while sitting near a window with open blinds, in full view of the parking lot and visitors. The LPN did not close the blinds or provide other privacy measures. Similarly, another resident with osteomyelitis of the vertebra and sacral region underwent wound care with open blinds, exposing the resident to the parking lot and a resident outside. The LPN admitted during an interview that she did not think about closing the blinds during the procedure. In all cases, the Director of Nursing confirmed that the expectation was for full privacy to be provided, including closing both privacy curtains and window blinds during resident care.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment in multiple resident rooms and common areas. Observations revealed missing and cracked plaster on two walls in Hall C, chipped floor tile near a bed in a room on Hall A, black marks and yellowish stains on a privacy curtain, and a feeding pump pole with a dried, brownish substance. The dried substance was also present on the floor around the feeding pump. These environmental issues were observed on multiple occasions and verified by housekeeping staff, the Housekeeping Supervisor, the Director of Nursing, and the Maintenance Director. The facility's policy requires weekly environmental rounds and prompt repairs, with a process for staff to report issues using a requisition form or communication slips. Interviews with staff indicated a lack of awareness and follow-through regarding the identified deficiencies. The Maintenance Director confirmed the need for wall repairs and was unaware of the chipped floor tile, noting that no communication slip had been submitted for it. Housekeeping staff acknowledged the presence of the dried substance and indicated that cleaning responsibilities were divided between nursing and housekeeping, with some confusion about who should address specific issues. The Housekeeping Supervisor stated that maintenance is responsible for curtain changes. The environmental concerns persisted over several days, indicating a failure to address and resolve the deficiencies in a timely manner.
Failure to Develop Comprehensive Care Plans for Oxygen Therapy and Indwelling Catheter
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents with specific medical needs. One resident, admitted with diagnoses including Parkinson's disease, hypertension, anxiety disorder, and depression, had a physician's order for oxygen therapy via nasal cannula as needed for shortness of breath, wheezing, or oxygen saturation below 92%. Despite documentation in the electronic medical record and the Minimum Data Set indicating the use of oxygen therapy, the resident's care plan did not reflect this intervention. Interviews with the MDS Coordinator and the Director of Nursing confirmed that the care plan did not address the resident's oxygen use, contrary to facility policy requiring comprehensive, person-centered care plans based on resident assessments. Another resident, admitted with conditions such as a displaced femur fracture, chronic kidney disease, and cystitis with hematuria, had a physician's order for an indwelling Foley catheter for urinary retention. The Minimum Data Set also indicated the presence of the catheter, but the resident's care plan did not include this intervention. The MDS Coordinator acknowledged responsibility for updating care plans and confirmed the omission, as did the Director of Nursing. These findings were based on record reviews, staff interviews, and facility policy review, demonstrating a failure to ensure care plans addressed all identified care needs for these residents.
Failure to Follow Physician's Wound Care Orders
Penalty
Summary
A deficiency occurred when a Licensed Practical Nurse (LPN) failed to follow a physician's order for wound care for a resident with a history of cerebral infarction and diabetes mellitus. The physician's order specified that the resident's left ankle wound should be cleansed with wound cleanser or normal saline, patted dry, treated with gentamicin ointment, and covered with a dry protective dressing such as an ABD pad, then secured with rolled gauze and tape daily or as needed if the dressing became dislodged or soiled. During an observed wound care procedure, the LPN chose not to use the rolled gauze as ordered, stating concern that it might come off if the resident rubbed her legs together. The LPN also acknowledged not replacing the dressing as needed because the rolled gauze was not used, despite the PRN order for replacement upon dislodgement or soiling. The LPN proceeded with the wound care by cleaning the area, applying the prescribed ointment, and covering the wound with a bordered dressing, but omitted the rolled gauze step. The Director of Nursing (DON) confirmed in an interview that nurses are required to follow physician's orders and that failure to do so constitutes a delay in care and neglect. The report documents that the physician's wound care order was not fully implemented as written for this resident.
Unsecured Oxygen Tank Creates Accident Hazard
Penalty
Summary
The facility failed to ensure an environment free from potential accident hazards by not properly securing an oxygen (O2) tank for a resident receiving oxygen therapy. Observations on multiple occasions revealed a free-standing, unsecured O2 tank located behind the resident's bed. The resident had diagnoses including acute respiratory distress and heart failure, and a moderate cognitive impairment as indicated by a BIMS score of 11. The resident had a physician's order for oxygen as needed at two liters per minute. Staff interviews confirmed that free-standing O2 tanks should not be stored in residents' rooms, as they could easily fall and cause injury. A CNA admitted to forgetting to remove the tank after patient care, and an RN was initially unsure of the policy due to being newly employed. The DON confirmed that under no circumstances should a free-standing O2 tank be stored in a resident's room and acknowledged that the tank had been present since the resident's recent readmission. The facility did not have a policy on accident hazards available for review.
Oxygen Therapy Not Administered as Ordered
Penalty
Summary
Staff failed to administer oxygen therapy to a resident as ordered by the physician. The physician's order specified oxygen via nasal cannula at 2 liters per minute (LPM) as needed for shortness of breath, wheezing, or oxygen saturation below 92%. However, multiple observations over two days showed the resident's oxygen concentrator was set at 4 LPM, not the ordered 2 LPM. The resident was receiving oxygen at this higher rate via nasal cannula during each observation. Interviews with staff revealed that charge nurses were responsible for ensuring residents received oxygen as ordered, but the oxygen flow rate for this resident had not been checked that day. The LPN confirmed the discrepancy between the order and the actual setting. The Director of Nursing also confirmed the resident's order was for 2 LPM and acknowledged that the resident's care plan did not address the use of oxygen therapy, despite the resident receiving it.
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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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