Calhoun Crossing Of Journey Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Calhoun, Georgia.
- Location
- 1387 Highway 41 North, Calhoun, Georgia 30701
- CMS Provider Number
- 115340
- Inspections on file
- 17
- Latest survey
- March 29, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Calhoun Crossing Of Journey Llc during CMS and state inspections, most recent first.
Missing stop date for PRN psychotropic medication: A resident with a seizure disorder had a PRN lorazepam IM order for seizure activity that remained active without a required stop date. The facility policy required PRN psychotropic orders to have a set duration, and staff, including an LPN/Unit Manager and the DON, confirmed the order lacked the 14-day stop date.
The facility failed to implement comprehensive care plans for three residents, leading to deficiencies in fall prevention and care planning. One resident's care plan did not address his desire for prostheses, another resident's bed was not kept in a low position as required, and a third resident fell due to inadequate staff assistance during incontinence care. These oversights were acknowledged by facility staff, highlighting a breakdown in care plan implementation.
A resident with bilateral above-the-knee amputations did not receive the necessary follow-up for prostheses fitting, despite being evaluated as ready and expressing a strong desire for independence. The facility failed to arrange the required appointments, leading to the resident's emotional distress. Interviews with staff revealed communication lapses and a lack of follow-through on the resident's care plan.
Two residents experienced falls due to inadequate supervision and failure to adhere to care plans. One resident, requiring two-person assistance, fell and was injured when a CNA provided care alone. Another resident, with a care plan requiring a low bed position, fell when the bed was not maintained in the correct position. Staff interviews confirmed these deficiencies.
The facility's QAPI plan was incomplete, lacking specific facility information and data-driven measures to address resident care and safety. The plan did not include tracking, trending, or performance measurements on clinical concerns, nor did it show feedback from staff, residents, or family members. The Administrator confirmed the plan was sourced online, potentially affecting all 91 residents.
The facility failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to two residents, preventing them or their representatives from making informed decisions about financial liabilities for services not covered by Medicare. The residents remained in the facility after their skilled services ended without receiving the necessary notices, as confirmed by the Administrator.
The facility failed to provide written notification of hospital transfers for three residents, as required by federal regulations. The deficiency was due to the absence of a policy ensuring written notices were given to residents or their representatives. This was confirmed through interviews with the Administrator and DON, who acknowledged the lack of enforcement of this requirement.
The facility failed to complete accurate PASARR assessments for two residents. One resident's PASARR was outdated, and another's inaccurately reflected their mental health diagnoses, despite documented conditions such as PTSD and major depressive disorder. The facility's policy lacked guidance on addressing inaccurate PASARRs, contributing to these deficiencies.
The facility failed to include required language in its arbitration agreements for two cognitively intact residents, indicating that signing was not mandatory for admission or continued care. The Business Office Manager confirmed the omission during an interview, revealing a lack of awareness of this requirement.
The facility failed to provide timely access to personal funds for three residents due to restricted banking hours, limited to weekdays from 9:00 AM to 3:00 PM. Residents expressed a desire for weekend access, which was previously available but had been discontinued. Interviews with staff confirmed the lack of access outside these hours, despite the Administrator's expectation for reasonable access.
The facility failed to provide quarterly financial statements to two residents, one cognitively intact and one mildly impaired, whose funds were managed by the facility. The Medical Records Director sent statements to resident representatives instead, contrary to the Administrator's expectation for capable residents to receive their own statements.
The facility failed to release funds from Personal Needs (PN) Accounts to residents or their Responsible Parties (RP) within the federally mandated 30 days after discharge. This deficiency affected three residents who had passed away, with balances remaining in their accounts for several months. Interviews with facility staff confirmed the oversight, with no clear explanation provided for the delay.
The facility failed to provide written notification of its Bed Hold Policy to residents or their representatives prior to hospital transfers. Three residents were hospitalized without documented evidence that the policy was communicated in writing, despite the facility's policy requiring it. The administrator confirmed the absence of documentation, indicating non-compliance with the policy.
A facility failed to refer a resident for a Level II PASARR evaluation after a new diagnosis of major depressive disorder. Despite the facility's policy requiring such referrals for newly evident serious mental disorders, no PASARR Level II was submitted following the diagnosis. The resident was initially admitted without this diagnosis, but later evaluations and care plans indicated the presence of major depressive disorder and the use of antidepressant medication.
A resident receiving enteral nutrition via a PEG tube had their feeding bag improperly labeled, lacking essential information such as date, time, and resident's name. The LPN on duty confirmed the oversight, attributing it to the night shift nurse. Interviews revealed a lack of accountability and adherence to the facility's policy, which mandates proper labeling for safety and compliance with clinical standards.
Two residents with Type 2 Diabetes experienced medication administration errors involving insulin pens, resulting in a 6.06% error rate. One LPN failed to leave the needle in the skin for the required time, while another did not prime the pen needle before administration. Both actions were contrary to the facility's insulin policy.
The facility failed to maintain effective infection control for two residents. One resident, COVID-19 positive, was not properly isolated as staff entered without PPE, despite clear droplet precaution signage. Another resident's catheter tubing was observed on the floor, risking infection. The facility's policies on isolation and catheter care were not followed, leading to these deficiencies.
The facility failed to administer pneumococcal vaccines according to CDC guidelines for two residents over the age of 65. One resident received the PCV15 vaccine but was not offered the PPSV23 within the recommended timeframe, while another received the PPSV23 but was not offered the PCV15 or PCV20. The RN responsible did not transfer the due dates to her tracking log, leading to the oversight. The interim IP and DON were unaware of these lapses, and the Administrator expected timely vaccine administration.
Missing stop date for PRN psychotropic medication
Penalty
Summary
The facility failed to ensure a stop date was implemented, not to exceed 14 days, for a psychotropic medication ordered for one resident. The resident had an order dated 10/23/2025 for lorazepam injection solution 2 mg/ml to be given intramuscularly every 12 hours as needed, and the order did not include a stop date. A review of the facility policy titled Use of Psychotropic Medication(s), dated 03/20/2025, stated that PRN psychotropic medication orders require a specified duration over 14 days with a clinical rationale and cannot be renewed for longer than 14 days without a direct evaluation by the prescriber. A pharmacist consultation report dated 12/22/2025 noted that the resident had an order for lorazepam 20 mg, administered as 2 mg/ml intramuscularly every 12 hours as needed for seizure activity, and that the order had been in effect for more than 14 days without a specified stop date. The pharmacist recommended discontinuing the PRN lorazepam or, if discontinuation was not possible, documenting the indication, intended duration, and rationale for extended use. During interviews, an LPN and Unit Manager stated that a 14-day stop date is required for psychotropic medications but confirmed that this resident did not have one, and the DON acknowledged that the resident's PRN lorazepam did not have the required stop date.
Deficiencies in Care Planning and Fall Prevention
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for three residents, leading to deficiencies in fall prevention and care planning. For one resident with bilateral above-the-knee amputations, the care plan did not address his desire for bilateral prostheses and independence with ambulation, despite his goal to return home. The facility's care plan only focused on coping skills for limb loss, neglecting the resident's expressed wishes. Another resident, diagnosed with Alzheimer's Disease and severely cognitively impaired, was at risk for falls due to balance problems and lack of safety awareness. The care plan required the bed to be in the lowest position to prevent falls, but observations revealed the bed was consistently at regular height. This oversight was acknowledged by the facility's Administrator and DON, who confirmed that care plans should be followed as documented. A third resident, with hemiplegia and morbid obesity, required two-person assistance for incontinence care. However, a CNA, unaware of this requirement, attempted to provide care alone, resulting in the resident falling out of bed and sustaining a broken finger. The CNA admitted to not reviewing the care plan or receiving proper training, and the DON confirmed the fall was due to the care plan not being followed. The MDSC verified that the care plan was accessible to all CNAs, indicating a communication breakdown in care plan implementation.
Failure to Provide Prostheses for Resident with Bilateral Amputations
Penalty
Summary
The facility failed to provide appropriate adaptive equipment as directed by Physical Therapy recommendations for a resident with bilateral above-the-knee amputations. The resident, who was cognitively intact, had been admitted with diagnoses including diabetes and required supervision for bed mobility and transfers. Despite making consistent progress in physical therapy and being evaluated as ready for prostheses, the facility did not ensure the resident received the necessary follow-up appointments for fitting the prostheses. The resident had been evaluated by a Certified Prosthetist/Certified Orthotic Assistant, who confirmed the resident's readiness for bilateral prostheses. However, there was no evidence in the clinical record that a follow-up appointment was made to fit the resident with the prostheses. The resident repeatedly expressed his need for the prostheses to promote his independence, and his emotional distress was noted by staff and during interviews. Interviews with facility staff, including the Director of Rehabilitation and Nurse Practitioners, revealed a lack of communication and follow-through regarding the resident's prostheses. The facility's scheduler, responsible for arranging community appointments, was on leave, contributing to the oversight. The resident's emotional state was affected by the delay, as he was eager to regain independence and return home with the use of prostheses.
Failure to Prevent Falls Due to Inadequate Supervision and Care Plan Adherence
Penalty
Summary
The facility failed to prevent a fall for two residents, R10 and R47, resulting in harm to R10. R10, who was moderately cognitively impaired and required assistance from two staff members for incontinence care, fell off the bed when a CNA provided care alone. The CNA was unaware of the two-person assistance requirement and did not review R10's care plan. This resulted in R10 suffering a closed head injury, a laceration to the forehead, and a fracture of the fifth finger on the right hand. R47, who was severely cognitively impaired and required assistance for transfers, experienced an unwitnessed fall while attempting to transfer from bed to wheelchair. The care plan for R47 included keeping the bed in the lowest position to prevent falls. However, observations revealed that the bed was not consistently kept in the low position, and there was no sign to remind staff of this requirement. The failure to maintain the bed in the correct position contributed to the fall. Interviews with staff and family members confirmed the deficiencies in following care plans for both residents. The CNA involved in R10's care was not informed of the two-person assistance requirement, and the staff responsible for R47's care did not ensure the bed was kept in the low position. The facility's policies on fall prevention and adherence to care plans were not effectively implemented, leading to these incidents.
Incomplete QAPI Plan Lacks Data-Driven Measures
Penalty
Summary
The facility failed to develop a comprehensive Quality Assurance Performance Improvement (QAPI) plan that effectively addressed resident care, safety, quality of life, and resident choice. The QAPI plan, dated 2022 and prepared by Compliance Store, was intended to establish a data-driven, facility-wide program to improve the quality of care and services. However, the plan was found to be incomplete, lacking specific facility information and failing to address potential quality of care issues. Notably, the plan did not include data-driven information such as tracking and trending, or performance measurements on specific clinical concerns. Additionally, the facility's QAPI plan did not demonstrate any feedback from staff, residents, or family members regarding identified potential deficient practices. During an interview, the Administrator acknowledged presenting the QAPI plan to the survey team and confirmed that the plan was printed from an online source. This lack of a detailed and facility-specific QAPI plan had the potential to affect all 91 residents currently living in the facility.
Failure to Provide SNFABN Notices to Residents
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to two residents, R145 and R146, which is necessary for informing them or their representatives about potential financial liabilities for services not covered by Medicare. The deficiency was identified through interviews, record reviews, and facility policy reviews. The facility's failure to issue the SNFABN prevented the residents or their representatives from making informed decisions regarding the costs of continued therapy services after the end of their skilled services. For resident R145, the facility's records indicated that skilled services ended on 08/21/24, yet the resident remained in the facility without receiving the SNFABN. Similarly, for resident R146, skilled services ended on 08/08/24, and the resident also stayed in the facility without receiving the necessary notice. During an interview, the Administrator acknowledged that the previous social services staff member was responsible for distributing the ABN notices, but confirmed that only the Notice of Medicare Non-Coverage was provided to the residents' representatives, not the SNFABN.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide written notification regarding the reason for hospital transfers for three residents, which is a requirement under federal regulations. The facility did not have a policy in place to ensure that written notices were given to residents or their representatives when a transfer to the hospital occurred. This deficiency was confirmed through interviews with the Administrator and the Director of Nursing, who acknowledged the absence of such a policy and the lack of enforcement of the requirement. The deficiency involved three residents who were transferred to the hospital without written notification being provided to them or their responsible parties. One resident, who was severely cognitively impaired, was transferred twice due to medical issues without written notice to his representative. Another resident, experiencing altered mental status and other symptoms, was sent to the emergency room without written notification to the resident or their responsible party. Similarly, a third resident was transferred to the hospital due to a medical condition without written notice being provided. The Administrator confirmed the lack of documentation for these notifications during an interview.
Failure to Complete Accurate PASARR Assessments
Penalty
Summary
The facility failed to complete the required Pre-Admission Screening and Resident Reviews (PASARR) for two residents, leading to deficiencies in their care. For one resident, identified as R31, the PASARR Level I was dated over 30 days before the resident's admission, which did not meet the facility's expectation to complete a new PASARR if the previous one was outdated. The resident was currently receiving mental health services, indicating the need for an updated assessment. For another resident, identified as R64, the PASARR Level I inaccurately indicated the absence of a major mental illness diagnosis, despite the resident having documented diagnoses of PTSD, anxiety disorder, and major depressive disorder. The resident's care plans and physician orders reflected these conditions, and the Director of Nursing confirmed the inaccuracy of the PASARR. The facility's policy did not address the responsibility for correcting inaccurate PASARR assessments, contributing to the oversight.
Arbitration Agreement Language Deficiency
Penalty
Summary
The facility failed to include specific language in its arbitration agreement for two residents, which is a requirement to ensure that residents and their families are informed of their rights. The arbitration agreement did not explicitly state that signing the agreement was not a condition for admission or continued care at the facility. This omission was identified during a review of the facility's documents and interviews with staff. The Business Office Manager confirmed that the current admission agreement lacked the necessary language, indicating a lack of awareness of this requirement. Two residents, who were cognitively intact as indicated by their BIMS scores, signed the arbitration agreements without being informed that it was not mandatory for their admission or continued care. The residents' electronic medical records and the facility's arbitration agreements were reviewed, revealing the absence of the required language. The Business Office Manager, responsible for completing the admission packets, acknowledged the deficiency during an interview, confirming that the agreements did not contain the necessary information.
Limited Access to Resident Funds Due to Restricted Banking Hours
Penalty
Summary
The facility failed to ensure the timely availability of personal resident funds for three residents, as the banking hours were limited to Monday through Friday from 9:00 AM to 3:00 PM, with no access on weekends. This deficiency was identified through record reviews and interviews with residents and staff. Resident 3, who was moderately cognitively impaired, expressed a desire to access her funds on weekends, which was previously possible but had since been restricted. Resident 31, who was cognitively intact, also wished to access his funds daily, including weekends, but was unable to do so due to the limited banking hours. Resident 37, who was mildly cognitively impaired, wanted to access her funds on Sundays to give money to her son for purchases, but was similarly restricted by the facility's banking schedule. Interviews with the Medical Record Director and the Business Office Manager confirmed that residents could not access their personal needs accounts outside the posted banking hours. The Medical Record Director, responsible for the personal needs accounts, acknowledged the lack of access during evenings and weekends. The Business Office Manager and the Administrator confirmed this limitation, with the Administrator stating her expectation that residents should have reasonable access to their personal funds. Despite this expectation, the facility's current banking hours did not accommodate residents' needs for accessing their funds outside of the specified times.
Failure to Provide Quarterly Financial Statements to Residents
Penalty
Summary
The facility failed to ensure accurate financial accounting and record retention for two residents, R31 and R37, regarding their Personal Needs Accounts. R31, who was cognitively intact with a BIMS score of 15, confirmed that the facility managed his money but did not provide him with a quarterly statement of his account. Similarly, R37, who was mildly cognitively impaired with a BIMS score of 12, also confirmed that she did not remember receiving quarterly statements for her account. The Medical Records Director acknowledged that the facility was managing funds for both residents and confirmed that neither received their quarterly statements. Instead, the statements were sent to the Resident Representative listed in each resident's record, following the director's process of sending statements to representatives regardless of the resident's cognitive ability. The Administrator stated that her expectation was for cognitively intact residents capable of understanding their finances to receive their quarterly statements.
Failure to Release Resident Funds Timely
Penalty
Summary
The facility failed to release resident funds managed in Personal Needs (PN) Accounts to the residents or their Responsible Parties (RP) within 30 days of discharge, as required by federal regulations. This deficiency was identified for three residents, each of whom had passed away in the facility. Resident R195, who had Alzheimer's Disease and respiratory failure, passed away over 13 months prior to the survey, yet still had an active PN Account with a balance of $4882.92. Similarly, Resident R197, with type 2 diabetes, passed away over four months prior, with a remaining balance of $233.00 in their PN Account. Resident R199, diagnosed with liver and colon cancers, passed away nearly seven months before the survey, leaving a balance of $170.00 in their account. Interviews with facility staff, including the Medical Records Director and the Administrator, confirmed the existence of these balances and the failure to return the funds to the respective RPs. The Medical Records Director was unable to provide an explanation for the delay in returning the funds. The Administrator acknowledged the deficiency, stating that the facility's expectation was to return funds within 30 days of discharge, in accordance with federal regulations. This oversight indicates a lapse in the facility's management of resident funds, affecting the timely conveyance of funds to the appropriate parties.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of its Bed Hold Policy to residents or their representatives prior to hospital transfers, as required by its own policy. This deficiency was identified through a review of records for three residents who were hospitalized. Resident 64, who was severely cognitively impaired, was transferred to the hospital twice for medical issues, but there was no documentation indicating that his spouse, who was his representative, received the bed hold policy in writing. Similarly, Resident 70 was transferred to the hospital on two occasions due to altered mental status and lethargy, yet there was no evidence that the bed hold policy was communicated to the responsible party in writing. Additionally, Resident 94 was sent to the emergency room due to a significant drop in pulse and oxygen levels, as well as a concerning physical finding, but again, there was no documentation of the bed hold policy being provided in writing. The facility's administrator confirmed the absence of such documentation in the residents' records and acknowledged that the facility's policy was not followed. This oversight created the potential for residents and their representatives to be uninformed about their rights regarding bed hold procedures during hospital transfers.
Failure to Submit PASARR Level II for Resident with New Mental Health Diagnosis
Penalty
Summary
The facility failed to make a referral for a Level II Preadmission Screening and Resident Review (PASARR) evaluation for a resident who was diagnosed with major depressive disorder. The facility's policy, as outlined in a document titled 'Resident Assessment-Coordination with PASARR Program' dated 02/12/22, requires that any resident exhibiting a newly evident or possible serious mental disorder be promptly referred to the state mental health authority for a Level II resident review. Despite this policy, the facility did not submit a PASARR Level II evaluation for the resident after a psychiatric provider diagnosed them with major depressive disorder on 01/04/24. The resident, identified as R31, was admitted to the facility without a diagnosis of major depressive disorder, as indicated in a PASARR Level I document dated 05/05/23. However, a psychiatric diagnostic evaluation later identified the resident with major depressive disorder, and the resident's care plan dated 05/13/24 noted the use of antidepressant medication for this condition. Despite these developments, the facility's records did not show evidence of a PASARR Level II submission following the new diagnosis. During an interview, the Administrator confirmed that the expectation was for social services to submit a new PASARR when a new mental health diagnosis is identified.
Failure to Label Enteral Feeding Bag
Penalty
Summary
The facility failed to label an enteral feeding bag according to professional standards for a resident with a history of dysphagia following cerebral infarction and gastroparesis. The resident was receiving enteral nutrition via a PEG tube, as per physician orders, which specified the feeding schedule and rate. However, during an observation, it was noted that the feeding bag lacked essential labeling information such as the date, time started, resident's name, and initials. This omission was confirmed by the LPN on duty, who stated that the night shift nurse was responsible for hanging the bag and should have completed the label. Interviews with the nursing staff revealed a lack of clarity and accountability regarding the labeling process. The LPN who worked the night shift admitted to not checking the label, although she was assigned to the resident. The Director of Nursing confirmed that it was standard practice to complete the labels for safety reasons, as enteral feeding is only viable for 24 hours. The facility's policy and competency documents also emphasized the importance of proper labeling to ensure compliance with clinical standards and prevent complications.
Medication Administration Errors in Insulin Delivery
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 6.06% error rate during the survey. This deficiency was identified through the review of medication administration for two residents, both diagnosed with Type 2 Diabetes, who were receiving insulin via pen injectors. The first resident, R54, was administered insulin by an LPN who did not leave the insulin pen needle inserted in the resident's skin for the required six to ten seconds, potentially affecting the full absorption of the medication. The LPN admitted to being unaware of this requirement, which was outlined in the facility's insulin policy. The second resident, R79, was administered insulin by another LPN who failed to prime the insulin pen needle before administration, which is necessary to ensure no air is injected instead of insulin. The LPN stated she had not been instructed to prime the needle unless air was visible in the pen chamber. The Director of Nursing confirmed that the facility's policy required priming the insulin pen with two units before each administration and leaving the needle in the skin for the specified duration to ensure proper medication delivery.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection control program for two residents, leading to potential health risks. One resident, who was COVID-19 positive, was not properly isolated as staff failed to don personal protective equipment (PPE) before entering the resident's room. Despite clear signage indicating droplet precautions and the presence of a PPE cart outside the room, a Certified Nurse Aide (CNA) entered without wearing the necessary protective gear. The interim Infection Preventionist and the Director of Nursing acknowledged the oversight and confirmed that no recent in-services had been provided to staff regarding isolation precautions. Another deficiency was observed with a resident who had an indwelling catheter. The catheter tubing was repeatedly observed in contact with the floor, which poses a risk of infection. The resident, who had diagnoses including Down Syndrome and urinary retention, was unable to communicate effectively due to cognitive impairments. Despite multiple observations throughout the day, the catheter tubing remained on the floor, and a CNA confirmed that it should not be in contact with the floor to prevent infection. The facility's policies on transmission-based precautions and catheter care were not adhered to, as evidenced by the staff's actions and the condition of the residents' care. The Director of Nursing and the Administrator both stated their expectations for staff to follow infection control policies, yet the observed practices did not align with these expectations, leading to the identified deficiencies.
Failure to Administer Pneumococcal Vaccines Timely
Penalty
Summary
The facility failed to offer the pneumococcal vaccination in accordance with CDC guidelines for two residents, R48 and R55, who were over the age of 65. R48 was admitted to the facility and had signed a consent form to receive a pneumococcal vaccine. The resident was administered the PCV15 vaccine, but the follow-up PPSV23 vaccine was not offered or administered within the recommended timeframe of one year. This oversight occurred because the registered nurse (RN2) did not transfer the due date for the next vaccination from the consent form to her tracking log, leading to the omission. Similarly, R55 was administered the PPSV23 vaccine but was not offered the subsequent PCV15 or PCV20 vaccine within the recommended timeframe. The same RN2 was responsible for this oversight, as she failed to transfer the due date to her tracking log. The interim Infection Preventionist and the Director of Nursing were unaware of these lapses, and the Administrator expected the staff to obtain consent and administer vaccines timely. These failures had the potential to increase the risk for the residents to contract pneumonia.
Latest citations in Georgia
Surveyors found that clean linens and personal clothing were stored and staged in close proximity to the dirty laundry area, with an open door between the clean and soiled sides and all washer and dryer doors open. Clean resident clothes, unlabeled garments, and bagged items were placed next to dryers and directly in front of the dirty linen room, and dirty barrels had to be pushed past racks of clean clothing to reach the washers, contrary to facility policies requiring separation of clean and soiled linens. Environmental staff believed keeping doors open and covering dirty barrels reduced infection spread, while the Environmental Services Director, IP nurse, and Administrator acknowledged that the dirty room door should be closed, linens should not be on dirty barrels, and clean resident clothing should not be stored in that location.
A resident with a suprapubic catheter, colostomy, sacral wound, and dependence on staff for bathing and hygiene was care planned for Enhanced Barrier Precautions (EBP), including use of PPE during high-contact care. During observed catheter care and a bed bath, a CNA wore only gloves and did not don a gown, despite EBP signage and a star posted on the door and PPE supplies available outside the room. In interviews, the CNA admitted forgetting to wear a gown and not recognizing additional required actions, while the IP nurse and DON confirmed that staff had been educated that gowns and gloves are required for high-contact care involving indwelling devices and wounds under the facility’s EBP policy.
A resident with multiple neurologic and psychiatric diagnoses, intact cognition, and unilateral functional limitations was found with an open box of lubricant eye drops stored at the bedside without any documented assessment for self-administration or prescriber’s order for self-administration or bedside storage, contrary to facility policy. Observations on multiple days confirmed the eye drops remained at the bedside, while staff interviews showed that CNAs and the IP recognized that residents were generally not to self-administer medications and that bedside medications required assessment and orders. The Administrator confirmed that the resident should not have had eye drops in the room and that residents with bedside medications are typically assessed for self-administration, and staff acknowledged that unsecured eye drops at the bedside could be accessed or ingested by other residents and cause harm.
The facility failed to maintain a safe, clean environment when multiple ceiling tiles throughout the building, including above a resident’s bed, near the nurses’ station, in a glass day room above a resident’s chair, and in a main hall, were observed with brown circular stains, bulging, and a white moldy substance. The Maintenance Director confirmed the stained and bulging tiles, acknowledged the risk that tiles above a resident’s bed could fall, and attributed the condition to rain-related roof leaks. The Administrator also confirmed that roof leaks and recent rainfall caused the brownish stains despite her reported daily rounds.
A resident with severe cognitive impairment, on hospice and fully dependent for ADLs, was sexually abused when another cognitively impaired male resident with a long-standing history of sexually inappropriate behavior toward female residents entered her room and placed his hand inside her pants. The abusing resident had multiple dementia and psychiatric diagnoses, was care planned for sexually inappropriate behaviors with prior documented incidents, and was on psychotropic medication for OCD-related sexual obsession. Despite these known risks and existing care plan interventions, he was able to access the female resident’s room and make inappropriate physical contact, and the facility’s investigation substantiated the abuse.
Surveyors found that the facility failed to develop and implement complete, person-centered care plans for two residents. One resident was receiving an antipsychotic (Haloperidol) for schizophrenia with associated behavior and side-effect monitoring orders, but there was no corresponding care plan addressing antipsychotic use or its indication. Another resident had an indwelling Foley catheter for neurogenic bladder related to prostate cancer, with goals to prevent catheter-related trauma; however, the care plan omitted key interventions such as balloon volume parameters and use of a leg strap or securement device, despite physician orders requiring a leg strap and observations showing the catheter positioned under the leg without securement. An MDS coordinator and the administrator acknowledged that required interventions and standard catheter care components were missing from the care plans.
A resident with a history of resistiveness to care and noncompliance with the non‑smoking policy had a comprehensive care plan that was not updated to reflect multiple interventions implemented in response to repeated smoking and vaping violations. Although the care plan noted the need for supervision while smoking and review of the smoking policy, it did not include measures such as daily room searches for smoking materials, added smoke detection in the room, relocation closer to the nurses’ station, q2h visual rounds for smoke, post‑outing nursing checks, initiation of a PAR process for vaping, or issuance of a discharge notice. Facility forms showed inconsistent documentation of daily room searches and incomplete IDT documentation on the PAR tracking, despite multiple documented episodes of policy violations and removal of vaping devices.
A cognitively intact but physically impaired resident with a history of noncompliance with the facility’s non‑smoking policy repeatedly smoked and vaped in his room while keeping multiple vape devices and other items at bedside. The facility’s Smoking Policy required that non‑compliant smokers have daily documented searches and be prohibited from keeping smoking materials in their rooms, yet monitoring forms showed many days without documented searches, Patient at Risk tracking was incomplete, and staff acknowledged that daily room checks and frequent rounds were not consistently performed. Multiple staff, including a CNA, social worker, Infection Preventionist, MDS coordinator, Activities Director, and the Administrator, reported ongoing violations and repeated discovery of vape devices in the resident’s room, including during surveyor observations, demonstrating that the environment was not maintained free from accident hazards and that required supervision and monitoring were not reliably implemented.
Surveyors found that a treatment cart containing topical medications was left unlocked and unattended in a hall across from a resident’s room after wound care was completed by an LPN. The facility’s policy requires that medication carts and supplies be locked or attended and accessible only to licensed or otherwise authorized staff. During interviews, the LPN confirmed the cart had been left unlocked and unattended, the IP LPN confirmed the LPN’s report that the cart was left unlocked, and the Administrator stated that all medications, including topical medications, were expected to be locked when not in sight of authorized staff.
The facility failed to implement its infection prevention and control program by not operationalizing a documented Legionella water management plan despite having a written policy, and by not fully implementing Enhanced Barrier Precautions (EBP) for residents with indwelling devices and other risks. A resident with an indwelling urinary catheter had no EBP care plan or orders, no EBP signage, and staff providing catheter care wore only gloves without gowns, while multiple staff members reported not knowing what EBP was or misidentified who should be on EBP. Another resident receiving tube feeding had care initiated by an LPN who wore gloves but no gown and repeatedly touched her hair with the same gloved hands before handling the feeding tube and equipment, later acknowledging she should have changed gloves and was unaware of EBP requirements, even though other clinical staff stated gowns and gloves should be used for feeding tube care. A resident on isolation for C. diff had a door sign indicating isolation but no instructions for visitors on required PPE or to seek staff guidance, and the IP confirmed there was no system to direct visitors about precautions, contributing to the overall infection control deficiency.
Failure to Maintain Separation of Clean and Soiled Laundry
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to separation of clean and soiled linens. Facility policies titled “Infection Prevention and Control Program” and “Handling Soiled Linens” required that clean linen always be separated from soiled linen. During an observation of the laundry area, all washer and dryer doors were open in the clean linen area. Clean linens, including sheets, towels, blankets, and washcloths, were folded on a table to the left of the washer and dryer room. On the right side of the room, next to the dryers and directly in front of the open door to the dirty laundry room, there were residents’ clean clothes on a rack, piles of folded clean clothes to be hung, a rack of unlabeled clothes, and a bag of unlabeled clothes. Dirty laundry barrels had to be pushed past the clean clothing on the racks to reach the washers, placing soiled items in close proximity to clean items despite policy requirements for separation. Environmental staff working in the laundry stated they believed they were reducing the spread of infection by keeping all doors open, covering dirty barrels, and circulating air, and they explained that the uncovered rack and bagged clothes near the dirty area were no-name clothes sometimes distributed to residents in need. They also stated that the rack of clean personal resident clothing parked in front of the open dirty linen room door was awaiting distribution by a staff member who worked only at night. The Environmental Services Director reported that the door to the dirty side of the laundry should always be closed and that no linen should be on top of dirty barrels. The Infection Preventionist nurse, when shown pictures and concerns about cross-contamination, confirmed there was a problem in the laundry but stated she had not been aware of it previously. The Administrator stated that residents’ clothes should not be stored where they were observed and should be handed out immediately once clean, and that she expected the laundry to be organized to prevent cross-contamination between dirty and clean clothes.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff followed its Enhanced Barrier Precautions (EBP) policy for the use of personal protective equipment (PPE) during high-contact care. The facility’s EBP policy, updated February 2025, requires gowns and gloves for residents with wounds and/or indwelling medical devices, including urinary catheters and ostomies, when staff perform high-contact activities such as bathing, dressing, toileting, hygiene, and catheter care. The policy also directs that gowns and gloves be made available near or outside the resident’s room and that EBP be implemented for residents with indwelling devices or wounds, even if they are not known to be infected or colonized with a multidrug-resistant organism. The resident involved had a suprapubic catheter, colostomy, sacral wound, and neurogenic bladder and bowel, and was care planned for EBP implementation during catheter and skin care. The resident was cognitively intact but dependent on staff for bathing, dressing, toileting, hygiene, bed mobility, and transfers, and used an indwelling catheter and ostomy. During an observation, a CNA provided suprapubic catheter care and a bed bath to this resident while only wearing gloves, despite EBP signage and a star posted on the door and PPE supplies available outside the room. The CNA did not don a gown and was unable to identify any additional actions needed before care until prompted about the EBP signage, at which point he acknowledged he should have worn a gown but forgot. In a subsequent interview, the IP nurse and DON confirmed that staff had been educated that gowns are required during high-contact care for residents with catheters, colostomies, and other devices, and that the posted signage and star were intended to alert staff to the need for enhanced PPE use.
Failure to Assess and Obtain Orders for Self-Administration and Bedside Medication Storage
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policies for self-administration of medications and bedside medication storage for one resident. The facility’s policies require that residents who wish to self-administer medications must be assessed by the interdisciplinary team for cognitive, physical, and visual ability, and that a prescriber’s order for self-administration and bedside storage must be present in the medical record and reflected on the MAR and medication label. For the resident in question, who had diagnoses including cerebral infarction, major depressive disorder with psychotic symptoms, PTSD, hemiplegia and hemiparesis, speech and language deficits, and cerebral atherosclerosis, the EHR showed no assessment for self-administration and no physician order for self-administration or bedside storage, despite active ophthalmic medication orders. The resident’s MDS documented intact cognition with a BIMS score of 15, use of corrective lenses, and functional limitations in range of motion on one side of both upper and lower extremities. Surveyor observations on two consecutive days found an open box of lubricant eye drops on the resident’s bedside table. Staff interviews revealed inconsistent understanding and enforcement of the facility’s policies. A CNA stated that residents did not self-administer medications and that only nurses administered them, but also reported that when she previously reported the eye drops, she was told the resident could have them because he was independent. The Infection Preventionist acknowledged the resident had an order for eye drops and believed he obtained them from the VA, and stated he should not have the lubricant eye drops because they were a hazard for other people. The Administrator confirmed that typically a resident with medications at the bedside should be assessed for self-administration and stated the resident should not have eye drops in his room. The report notes that unsecured medications at the bedside had the potential to cause adverse reactions if accessed or ingested by other residents.
Failure to Maintain Safe and Clean Ceiling Surfaces Throughout Facility
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable homelike environment as required by its Maintenance Service policy, which assigns the Maintenance Department responsibility for keeping the building in good repair and free from hazards. Surveyors observed multiple stained and damaged ceiling tiles in several areas of the facility, including near the nurses' station, in a resident bedroom (room [ROOM NUMBER]A), in the glass day room, and in the middle of the east hall. On several occasions, ceiling tiles near the nurses' station were noted to have tannish-brown circular stains of varying sizes, and at one point a white, moldy substance was observed on a ceiling tile in that same area. In room [ROOM NUMBER]A, surveyors observed brown rings roughly 16 inches in diameter on ceiling tiles located directly above a resident’s bed, with the Maintenance Director later confirming that these tiles were stained, bulging, and at risk of falling on the resident. Additional observations in the glass day room identified two stained ceiling tiles above a resident’s chair, each with brown circular stains approximately three inches in diameter. In the east hall, a ceiling tile with a brown circular stain approximately 10 inches in diameter was also documented. The Maintenance Director and the Administrator both acknowledged that the stains and damage were related to roof leaks associated with recent rainfall, and the Administrator confirmed awareness of roof leaks that had previously been repaired and that the brownish stains were due to recent rain.
Failure to Prevent Sexual Abuse of a Cognitively Impaired Resident by Another Resident
Penalty
Summary
The facility failed to protect a dependent, cognitively impaired resident (R113) from sexual abuse by another resident (R12). R113 had severe cognitive impairment with a BIMS score of 5, was on hospice care, and was fully dependent for toileting, bathing, dressing, footwear, and personal hygiene. On the day of the incident, a CNA observed R12 in R113’s room with his right hand inside R113’s pants while she was seated in a geriatric chair. Staff witness statements and nursing progress notes documented that R12 was found in R113’s room with his hand in her pants, and the facility’s investigation substantiated that R12 touched R113 inappropriately. R12 also had severe cognitive impairment with a BIMS score of 4 and multiple psychiatric and dementia-related diagnoses, including vascular dementia with mood disturbance, Alzheimer’s disease, major depressive disorder, obsessive-compulsive personality disorder, unspecified psychosis, and unspecified mood affective disorder. He required extensive physical assistance, used a manual wheelchair, and was fully dependent for toileting, bathing, lower body dressing, and footwear. R12’s care plan, in place since 2017, identified him as having sexually verbally and physically inappropriate behavior, including documented prior incidents in which he inappropriately touched or attempted to touch female residents. His care plan included interventions such as discussing his behavior when reasonable, explaining that it was inappropriate, intervening to protect others, diverting his attention, and removing him from situations as needed, as well as monitoring and recording occurrences of target behaviors such as sexual aggression toward others. Despite this known history of sexually inappropriate behavior toward female residents and the presence of care plan interventions, R12 was able to enter R113’s room and place his hand inside her pants. The Administrator confirmed that the CNA reported finding R12 in R113’s room with his hand in her pants while R113 was in her wheelchair, and that the facility’s investigation substantiated the abuse allegation. The facility’s abuse policy stated that it would not condone resident abuse by anyone, including other residents, and defined sexual abuse to include sexual harassment, sexual coercion, or sexual assault. The occurrence of this incident demonstrated that the facility did not effectively prevent sexual abuse of R113 by another resident, despite R12’s documented behavioral history and existing care plan.
Failure to Develop and Implement Complete Care Plans for Antipsychotic Use and Foley Catheter Management
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for identified resident needs, as required by its Comprehensive Care Plan policy. The policy states that care plans must address all needs identified in the comprehensive assessment, including medical, nursing, mental, and psychosocial needs, and must be developed within seven days after completion of the comprehensive MDS assessment. It also requires that all triggered Care Area Assessments (CAAs) and other factors identified by the IDT or resident preferences be incorporated into the plan of care. For one resident, R44, the clinical record showed physician orders for Haloperidol 10 mg by mouth twice daily for schizophrenia, along with orders for behavior monitoring and psychiatric medication side effect monitoring. Despite these orders, the resident’s care plan dated 03/11/2026 did not include any care plan addressing antipsychotic medication use or its indication. The MDS Coordinator stated that all residents receiving antipsychotic treatment should have a comprehensive care plan in place beginning with the date the medication was originally ordered, and upon review of the record confirmed that such a care plan was not present for this resident at the time of the survey. For another resident, R3, the care plan dated 03/13/2026 identified a problem of an indwelling catheter secondary to neurogenic bladder related to prostate cancer, with goals including remaining free from catheter-related trauma. The listed interventions included positioning the catheter bag and tubing below bladder level, monitoring and documenting intake and output per policy, and monitoring for pain, discomfort, and signs and symptoms of UTI. However, the care plan did not address the amount of water in the catheter balloon, use of a leg strap or securement device, or other securement measures. Physician orders specified checking a leg strap every shift and documented that the resident was admitted with an 18F catheter attached to a bedside drainage bag, but observations showed the Foley catheter positioned under the resident’s leg without a leg strap or securement device on two occasions, and a CNA reported being unaware that a leg strap was required. The MDS Coordinator confirmed that these ordered interventions were missing from the care plan.
Failure to Revise Care Plan for Ongoing Smoking Policy Noncompliance
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive care plan to reflect current interventions implemented in response to ongoing noncompliance with the facility’s non‑smoking policy. The facility’s policy requires that the comprehensive care plan be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment, and that it include measurable objectives, timeframes, and alternative interventions as needed, with qualified staff notified when changes are made. The resident’s care plan included a focus on resistiveness to care and noncompliance with smoking, noting that the resident continued to go outside beyond facility property to smoke, and an intervention to review the smoking policy with the resident. Another care plan focus identified the resident as a smoker requiring supervision while smoking, with interventions stating the resident required supervision while smoking and that the charge nurse should be notified if a smoking policy violation was suspected. Despite repeated and ongoing noncompliance with the non‑smoking policy, the care plan was not revised to include additional interventions that were actually implemented. These unreflected interventions included daily room searches for smoking paraphernalia, placement of a smoke detector in the resident’s room, relocation of the resident’s room closer to the nursing station, every‑two‑hour visual rounds to check for smoke, nursing checks upon return from outings, initiation of a Patient at Risk (PAR) process for vaping noncompliance, and issuance of a 30‑day discharge notice for repeated violations of the non‑smoking policy. Documentation on the Smoking Materials Monitoring Form showed initials on selected days only, indicating daily room searches were not consistently completed and documented for the entire month. The PAR Smoking Tracking form documented multiple observations of vaping in the room, repeated room checks, removal of vapor devices, and the resident’s refusal to comply with facility policies, with later weeks lacking IDT signatures and documentation, while the PAR Grid showed multiple prior entries for violating the non‑smoking policy.
Failure to Control Smoking and Vaping Hazards for a Noncompliant Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision for a resident with a known history of noncompliance with the facility’s non‑smoking policy. The facility’s Smoking Policy requires that residents not be allowed to keep cigarettes, cigars, pipes, matches, or lighters in their possession or rooms, and that non‑compliant smokers receive daily searches with documentation, while compliant smokers receive weekly searches. The policy also requires incident reports and review in a “Patients at Risk” process whenever smoking materials are found. Despite these written procedures, the resident’s Smoking Materials Monitoring Form for April showed multiple days without documented searches, indicating that required daily room searches were not consistently completed or recorded. The resident at issue was cognitively intact, with a BIMS score of 15, and had significant physical impairments including hemiplegia and hemiparesis on the left side, use of a manual wheelchair, and other neurologic and psychiatric diagnoses such as cerebral aneurysm, cerebral infarction, major depressive disorder with psychotic symptoms, PTSD, and speech and language deficits. The care plan identified the resident as resistive to care and noncompliant with smoking, noting that he continued to go outside beyond facility property to smoke, and also identified him as a smoker requiring supervision while smoking. Progress notes and Patient at Risk documentation showed a pattern of repeated violations of the non‑smoking policy, including multiple instances of vaping and smoking in his room, with staff repeatedly finding vape devices and other smoking paraphernalia in his possession and in his room. Throughout the period reviewed, staff observations and interviews confirmed ongoing noncompliance with the smoking policy and inconsistent implementation of the facility’s own interventions. Staff documented several occasions when the resident was observed vaping or smoking in his room, including in the presence of a state surveyor, and room searches revealed multiple vape devices hidden under the sheets. Staff interviews indicated that daily room checks were not always performed due to competing demands, that logs of every‑two‑hour rounds were not maintained, and that there was confusion or inconsistency regarding whether the resident could keep items such as air freshener at bedside. The social worker, Infection Preventionist, MDS coordinator, Activities Director, CNA, and Administrator all acknowledged that the resident’s room had to be searched for cigarettes and vaping paraphernalia and that prohibited items were repeatedly found, while documentation showed gaps in the required daily searches and incomplete follow‑through on the Patient at Risk tracking process. These actions and inactions resulted in the environment not being kept free from accident hazards as required by the facility’s policy and regulatory standards. The deficiency is further supported by the facility’s own records showing repeated entries on the Patient at Risk grid for violations of the non‑smoking policy over an extended period, as well as narrative notes describing the resident’s statements that he would continue to vape in his room and would simply obtain new devices if they were confiscated. Despite the known pattern of behavior and the facility’s policy requiring close supervision, daily searches, and thorough documentation for non‑compliant smokers, the monitoring forms and staff interviews demonstrate that these measures were not consistently carried out. The presence of multiple vape devices and cans of air freshener at the bedside during surveyor observations, along with staff acknowledgment that room checks were missed and that logs of frequent rounds were not kept, illustrate the facility’s failure to effectively implement its own safety procedures to prevent accident hazards related to smoking and vaping in the resident’s room.
Unlocked and Unattended Treatment Cart with Topical Medications
Penalty
Summary
Surveyors identified a deficiency related to medication storage when a treatment cart containing topical medications was left unlocked and unattended in a hall. The facility’s policy titled “Medication Storage in the Facility,” effective 10/01/2025, states that the medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff lawfully authorized to administer medications, and that medication rooms, carts, and supplies are to be locked or attended by authorized personnel. During an observation on 04/29/2026 at 9:35 AM, after wound care was provided to resident R3 by the wound care LPN, the treatment cart was observed left in the [NAME] hall across from R3’s room, unlocked and unattended for 30 minutes. In an interview, the wound care LPN confirmed that the treatment cart had been left unlocked and unattended. The Infection Preventionist LPN later confirmed that the wound care nurse told her the cart was left unlocked, and the Administrator stated that her expectation was that all medications, including topical medications, be locked when not in sight of a licensed nurse or authorized person. This deficient practice occurred in a facility with a census of 94 residents and involved the failure to follow the facility’s own policy requiring that medication carts be locked or attended by authorized personnel, resulting in unsecured access to topical medications on the treatment cart.
Failure to Implement Legionella Water Management and Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to provide and implement an infection prevention and control program, including a documented water management plan for Legionella and other waterborne pathogens, and a fully implemented Enhanced Barrier Precautions (EBP) program. The Administrator stated there was no Legionella water program in place, and the Maintenance Supervisor reported he was unaware of the requirement for such a program. This was despite the existence of a written Legionella Water Management Program policy, revised in September 2022, which described the need for an interdisciplinary water management team, detailed water system diagrams, identification of risk areas and situations for Legionella growth, control measures, monitoring systems, and annual review. Interviews confirmed that the expectation was that the facility would be conducting this water program, but it was not being done. The facility also failed to implement EBP for residents with indwelling medical devices and other risk factors, as required by its own policy. One resident with Alzheimer’s disease, urinary obstruction, and emphysema had an indwelling urinary catheter documented in the care plan and physician orders, but the care plan did not address EBP related to the catheter, and there was no order for EBP in the record. During catheter-related care, a CNA wore gloves but did not wear a gown, and there was no EBP signage or PPE setup at the room. Multiple staff members, including CNAs and a housekeeper who regularly worked on the resident’s hallway, reported they did not know what EBP was or incorrectly associated EBP only with residents on Transmission-Based Precautions. The DON acknowledged that an attempt to roll out EBP months earlier had not been completed, and that expected signage and PPE caddies for EBP were not fully in place. Additional infection control lapses were observed during tube feeding care and contact isolation. A resident receiving continuous tube feeding had a care plan and physician’s order for enteral nutrition, and an LPN initiated the feeding while wearing gloves but no gown. During the procedure, the LPN repeatedly touched her hair with the same gloved hands and then handled the feeding tube, pump, and syringe used to inject air and check residuals, only removing gloves and using hand sanitizer at the end. The LPN later acknowledged she should have changed gloves after touching her hair and stated she did not know what EBP was or that a gown was required for feeding tube care, while another LPN and the IP stated that EBP with gown and gloves should be used for feeding tube care and that staff should not touch their hair during care without changing gloves and performing hand hygiene. For a resident with a positive urine culture and a subsequent positive C. difficile culture who was on isolation, the door sign indicated isolation but did not provide instructions for visitors on required precautions or direct them to staff for guidance. The IP confirmed there was no system to direct visitors about PPE use for residents on contact isolation and acknowledged that visitors would not know to wear PPE if it was simply present in or on the door of the room. Overall, the survey findings show that the facility did not operationalize its written Legionella water management policy and did not consistently apply its EBP policy for residents with indwelling devices or wounds. Staff interviews and observations demonstrated a lack of knowledge and implementation of EBP, incomplete use of PPE during high-contact care activities such as catheter care and tube feeding, and unclear isolation signage that did not instruct visitors on appropriate precautions. These combined inactions and omissions in policy implementation, staff education, and practice led to the cited infection prevention and control deficiency.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
