Carrollton Crossing Of Journey Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Carrollton, Georgia.
- Location
- 2327 North Highway 27, Carrollton, Georgia 30117
- CMS Provider Number
- 115368
- Inspections on file
- 22
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Carrollton Crossing Of Journey Llc during CMS and state inspections, most recent first.
Unsafe Food Storage and Sanitation Practices: Surveyors observed expired and unlabeled food items, raw meat stored without leak-proof containment, food stored on the floor, dirty pantry and cooler areas, a contaminated ice machine, wet-nested dishware, and uncovered tray carts leaving the kitchen. The DKM and Administrator acknowledged that food should be labeled, dated, stored properly, and transported covered, and that staff food should not be kept in resident food storage areas.
Respiratory equipment was not maintained or used as ordered for three residents. One resident’s oxygen concentrator filter had heavy dust buildup while receiving O2 by NC, another resident’s BiPAP machine had no filter and the mask/tubing were not being sanitized or stored as ordered, and a third resident’s oxygen concentrator was observed with gray fuzzy buildup and set at 3.5L instead of the ordered 2L, with tubing left out of its bag when not in use.
Dusty PTAC Units in Resident Rooms: Two resident rooms on the 300 Hall had an excessive buildup of dusty grayish material on the PTAC units. The MD confirmed maintenance services the units and said they should be cleaned monthly, but the facility used a paper log with blank room and problem fields. An MA confirmed the buildup in both rooms, and the facility policy required routine cleaning and disinfection of visibly soiled surfaces in resident rooms.
A resident with an indwelling Foley catheter received catheter care for an extended period without a corresponding physician order, and staff confirmed the catheter had been in place continuously while the missing order went unnoticed. Another resident with multiple chronic conditions and bowel/bladder incontinence was hospitalized for nausea and vomiting caused by bowel impaction after the facility failed to include constipation in the care plan and did not complete adequate bowel monitoring.
Failure to provide restorative ROM and splinting services for a resident with a contracted left hand/wrist. The resident, admitted with neurocognitive disorder with Lewy bodies, falls, and OA, was documented as having full UE ROM earlier in the stay and no contractures on admission, but the care plan had no contracture prevention or restorative ROM interventions. During multiple observations, the resident’s left hand was contracted with no splint or other contracture management device in place, and the DON and regional RNs confirmed the contracture.
A resident with COPD, dementia, and other diagnoses was identified as needing a protective smoking apron while smoking, and the care plan called for supervision and burn monitoring. Surveyors observed the resident smoking in the designated area without the apron on multiple occasions while staff supervised, and staff reported the facility did not have the required vest/apron and that smoking education had not been provided since hire. On one observation, staff later applied the apron, provided a cigarette, and lit it for the resident.
Medication Error Rate Exceeded 5 Percent: The facility had a 12.5% medication error rate, with four errors in thirty-two opportunities. An RN administered scheduled G-tube meds when one aspirin could not be crushed and the correct alternative was not available, resulting in a late dose after a new order was obtained. In another event, an LPN found multiple meds unavailable for a resident, including Bumex, metoprolol, and citalopram; some were later pulled from the Pyxis after the scheduled time, and metoprolol was not given on one day. Staff interviews and record review showed repeated missing medications during med pass.
Failure to Perform Hand Hygiene During Wound and Foley Care: An LPN and a CNA were observed providing wound care and Foley catheter care to a resident with severe cognitive impairment, a Foley catheter, bowel incontinence, and a sacral wound. During both procedures, gloves were removed and replaced multiple times without hand hygiene, and the CNA also performed catheter care in an incorrect sequence while the Foley tubing was unsecured and the urine bag lacked a privacy cover. The LPN and CNA both stated they were nervous and did not fully remember the correct procedures.
A male resident with severe cognitive impairment entered the room of a female resident, also severely cognitively impaired, and inappropriately touched her upper thigh while trying to remove her bed covers. This incident was observed by a CNA, reported, and substantiated by facility investigation, revealing a failure to protect the resident from sexual abuse.
A resident with diabetes and severe cognitive impairment experienced a critically low blood sugar level that was not properly documented or addressed according to the facility's blood sugar protocol. The resident became unresponsive, required IM glucagon, and was transferred to the ER for further treatment. Staff interviews confirmed a lack of documentation and adherence to protocol in managing the resident's hypoglycemic episode.
Surveyors found that kitchen equipment, storage shelves, and food contact surfaces were unclean, with accumulations of food debris and grease. Dietary staff did not consistently label, date, or cover stored food and beverages, and some food items were left open and unprotected in storage areas. The ice machine and microwave were also found to be unclean. These failures were confirmed by the DM and Administrator and were not in accordance with facility policies.
Surveyors identified multiple infection control deficiencies in the laundry area, including a gap under the exterior door, broken wallboard with exposed insulation, debris buildup on air vents and floors, uncleanable unfinished molding, and soiled equipment such as reusable gloves and a floor fan. The Laundry Supervisor confirmed the need for repairs and cleaning.
Several cognitively intact residents reported receiving cold meals, especially at breakfast, with specific complaints about cold eggs, breakfast meat, and grits. Although food left the kitchen at proper temperatures, it was served on unheated plates and transported on a non-heated cart, resulting in cold food by the time it reached residents. Both a surveyor and an LPN confirmed the food was cold, and the Dietary Manager stated that available equipment to keep food hot was not used.
A resident with severe cognitive impairment and multiple diagnoses was not assessed for self-administration of medications, as required by facility policy, before medications were left at the bedside. There were no physician orders or care plan documentation authorizing self-administration, and the ADON confirmed the resident was not able to self-administer medications after pills were found on the resident's nightstand.
A resident with severe cognitive impairment was started on a new medication for OCD-related behaviors without prior notification to the responsible party. Documentation and interviews confirmed that the nurse did not inform the responsible party before administering the medication, and this omission was only discovered later by the ADON.
Two residents, both with significant cognitive and psychiatric conditions, were involved in a physical altercation in which they hit each other in the arm. Facility policy requires protection from abuse by anyone, including other residents, but the incident occurred, and both residents later blamed each other. No injuries were found on assessment, but the facility did not prevent the physical abuse from taking place.
A resident with severe cognitive impairment reported a possible abuse incident to an agency LPN, but the facility did not notify the State Agency as required by policy. The delay in reporting meant the allegation was not investigated promptly.
Two residents did not have comprehensive care plans reflecting their current needs. One resident with dementia and moderate cognitive impairment lacked a dementia care plan, while another with severe cognitive impairment and a newly identified sacral wound did not have the wound addressed in the care plan. An LPN confirmed these omissions.
A resident with Huntington's Disease and severe cognitive impairment, identified as a fall risk, slid off the bed while being changed by a CNA. The ADON completed the fall investigation by reviewing only the nurse's documentation and did not collect statements from the staff involved, resulting in an incomplete investigation.
A resident with ESRD and acute kidney failure who required dialysis did not have Dialysis Communication Forms completed by staff for multiple treatment dates, as required by facility policy. Interviews with the resident, ADON, DON, and RNC confirmed that the forms, which are essential for exchanging care and medication information between the facility and the dialysis center, were not filled out as expected.
A medication error rate above five percent was identified when an LPN administered incorrect doses of Allopurinol and Seroquel to a resident with gout and schizoaffective disorder. The LPN gave only half the prescribed dose of Allopurinol and the wrong dose of Seroquel during the morning pass, contrary to physician orders and facility policy.
A resident with diabetes was not served cereal at breakfast as specified on their tray slips and the facility's planned menus. Despite clear documentation and staff acknowledgment that cereal should have been provided, the resident did not receive it on multiple occasions, and staff confirmed the omission. This failure to follow the planned menu could have affected the nutritional needs of all residents receiving meals from the kitchen.
Three diabetic residents with physician orders for bedtime snacks did not consistently receive them, as confirmed by resident interviews and staff statements. Facility policy required snacks to be provided and labeled for diabetic residents, but the kitchen often failed to supply enough snacks or label them appropriately, resulting in some residents missing their prescribed bedtime snacks.
Unsafe Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to store, handle, and serve food in a safe and sanitary manner. During a kitchen tour, surveyors observed expired thickened orange juice in dry storage, an open bag of white bread without an open date or expiration date, and multiple food items in the cooler and freezer that were unlabeled, unsealed, or otherwise improperly stored. Surveyors also observed unknown sliced deli meat in an open plastic bag without a date label, staff personal food stored in the resident cooler without proper identification, and frozen hamburger patties, corn dogs, chicken tenders, and raw chicken stored in open or unlabeled bags. Surveyors further observed raw ground beef stored directly on top of a cardboard box in the cooler without a leak-proof container, with another cardboard box showing dark brown staining and dried liquid residue. Three onions were stored directly on the cooler floor, and the cooler floor had heavy accumulation of food debris, dried spills, residue, and scattered food particles. In dry storage, the pantry floor had heavy accumulation of food debris, dried food residue, and soiling beneath and around shelving units. The ice machine interior had a heavy accumulation of a black substance along the seams and corners, and dishware lids and cups were stored while still wet on mats that had visible food debris and residue. Surveyors also observed four tray carts leaving the kitchen uncovered, including a test tray cart. The Dietary Kitchen Manager and Administrator acknowledged the observations during interview and stated that food should be labeled, dated, rotated, stored off the floor, kept in clean and sanitary areas, and transported covered. They also acknowledged that raw meat should be stored in drip-proof containers, that wet nesting should not occur, and that staff food should not be stored in resident food storage areas.
Respiratory Equipment Not Maintained or Set as Ordered
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for three residents who were receiving oxygen therapy or using a BiPAP machine. During observations, R45 was seen receiving oxygen by nasal cannula at 3.0 to 3.5 liters, and the oxygen concentrator filter had a gray-like dust buildup. RN BB confirmed the filter had a considerable accumulation of dust-like particles and stated that unclean filters could cause respiratory distress. R45’s record showed diagnoses including chronic respiratory failure with hypoxia and COPD, and the physician order called for oxygen at 2L per minute via nasal cannula continuously with exertion and sleep. R104 was observed with a BiPAP machine that did not have a filter. The resident stated the mask was never sanitized, and RN FF confirmed there were no filters available in stock for weekly replacement. The care plan directed that the BiPAP be used as ordered, with the mask and tubing cleaned per manufacturer guidelines and the filter connected to the device as needed. The physician’s orders also required BiPAP at night and weekly changes of the bag, oxygen tubing, nebulizer mask, water, and date. A later progress note documented the resident’s oxygen concentrator filter was heavily soiled with dust and the oxygen flow rate was set at 3.5L/min before the RN adjusted it to the ordered 2L/min and replaced the concentrator. R56 was observed with an oxygen concentrator that had gray fuzzy material covering the back filter and vent, and the concentrator was set at 3.5L instead of the ordered 2L. On another observation, the oxygen tubing was lying on the bed rather than being stored in a bag when not in use. The resident’s record showed centrilobular emphysema, oxygen therapy, and an order for oxygen at 2L via nasal cannula to keep SpO2 above 92%, with tubing to be placed in a bag when not in use and changed and dated every Wednesday. Staff interviews showed uncertainty about who was responsible for cleaning the machine, while other staff stated nurses check oxygen tubing and rate and set the oxygen per physician orders.
Dusty PTAC Units in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable homelike environment when two resident rooms on the 300 Hall were observed with an excessive amount of dusty grayish buildup on the PTAC units. During observations on 4/7/2026 and 4/8/2026, the PTAC units in room [ROOM NUMBER] and room [ROOM NUMBER] were noted to have visible dusty gray-like buildup. The Maintenance Director confirmed that the maintenance department services the PTAC units, stated that one maintenance assistant is assigned to clean them throughout the facility, and said the units should be cleaned monthly. He also stated that he does not use procedures in the electronic maintenance system and instead uses a paper log. The Maintenance Assistant confirmed the buildup in the two rooms, and the Maintenance Director stated the cleaning would be done immediately. Review of the Maintenance Log (PTAC 2026) dated 1/7/2026 through 3/23/2026 showed the room number and problem/concern columns were blank, although the maintenance assistant’s signature was present. The facility policy titled Routine Cleaning and Disinfection stated that routine cleaning and disinfection of frequently touched or visibly soiled surfaces will be performed in common areas, resident rooms, and at discharge.
Missing Physician Orders for Foley Care and Incomplete Bowel Monitoring
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for two residents. One resident with diagnoses including cerebral infarction, Alzheimer’s disease, encephalopathy, acute kidney failure, and chronic kidney disease had an indwelling Foley catheter and was receiving hospice services. The resident’s care plan identified the catheter and included catheter-related interventions, but the record showed no physician order for catheter placement or catheter care for approximately 85 days after the catheter care plan was initiated. Staff documentation showed catheter care was being performed during that period, and the hospice plan of care also referenced the catheter, but the facility’s order summary did not show a formal facility physician order until later. Interviews with staff confirmed that the resident had a Foley catheter in place continuously since returning from the hospital in December 2025 and that catheter care had been provided before a corresponding facility physician order was entered. A CNA stated she had been providing catheter care since the resident first returned and documented the resident as having an indwelling catheter. An RN confirmed there was no physician order for catheter placement or catheter care until the order was entered later, and the DON stated she identified the missing order during a routine review and entered it into the system. The Administrator stated the resident should have had a physician order when returning from the hospital and that the order should have been entered at that time. A second resident with diagnoses including cerebrovascular accident, atherosclerotic heart disease, type 2 diabetes, kidney disease, heart failure, constipation, multiple sclerosis, vascular dementia, and major depressive disorder was cognitively intact on assessment but dependent for most ADLs and incontinent of bowel and bladder. The care plan did not include constipation care planning. The resident was hospitalized for nausea and vomiting, and the resident stated the hospitalization was due to not having a bowel movement for 3 weeks. The resident reported receiving an enema in the hospital and having a bowel movement, with improvement in nausea, and later stated she had not had a bowel movement since returning to the facility. The DON stated the hospitalization could have been prevented if the assessment had been more complete and that she was unable to review prior CNA bowel documentation at the time, although later documentation showed bowel movements after the resident returned from the hospital.
Failure to Provide Restorative ROM and Splinting Services
Penalty
Summary
The facility failed to provide restorative services for one of three sampled residents, R86, related to splinting and range of motion (ROM) services. R86 was admitted with diagnoses including neurocognitive disorder with Lewy bodies, a history of falls, and osteoarthritis. The admission Nursing Evaluation dated 9/3/2025 stated that R86 had no contractures on admission, and a Joint Range of Motion Screen dated 3/2/2026 documented full ROM in the upper wrist and fingers on both sides. However, the care plan dated 1/23/2026 did not include any plan related to contracture prevention/management or restorative ROM services. During observations on 4/7/2026, 4/8/2026, and 4/9/2026, R86 was seen resting in bed or sitting in a reclining chair with the left hand contracted, closed toward the palm, and the wrist turned inward; on the last observation, the fingernails were pressing into the skin. No splint was observed during any of the observations. On 4/9/2026, the DON and two regional RNs confirmed that R86's left wrist was contracted and that no splint, hand roll, or other contracture management device was in place. The physician stated he had no recall of being notified of contractures and said the facility should have restorative nursing and skilled therapy to guide recommendations.
Failure to Use Required Smoking Apron During Supervised Smoking
Penalty
Summary
The facility failed to ensure appropriate safety interventions were implemented and followed for one resident who smoked. The resident was admitted with diagnoses including an intracapsular fracture of the right femur, COPD, dementia, major depressive disorder, acute respiratory failure, and contracture of the right ankle. The resident’s smoker screen indicated that a protective assistive device, such as a smoking jacket or apron, was required while smoking, and the care plan stated that the resident smoked and was at risk for burns and other injuries, with interventions including supervision during smoking times and monitoring for burn areas. Observations on multiple occasions showed the resident going to and smoking in the designated smoking area without a smoking apron while staff supervised. On one occasion, a staff member later applied a smoking apron, provided a cigarette, and lit it for the resident. Interviews revealed that staff had been allowing the resident to smoke without the required smoking vest/apron because the facility did not have one, and one assistant stated she had not received education on smoking since being hired. The DON stated the facility was a non-smoking environment except for one grandfathered resident and that staff were expected to supervise smoking and assist with lighting cigarettes.
Medication Error Rate Exceeded 5 Percent
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5 percent, with four errors identified across thirty-two opportunities for a medication error rate of 12.5%. During an observation, an RN administered scheduled G-tube medications to a resident and prepared only two medications when three were due; the resident’s 325 mg aspirin EC could not be crushed, and a non-EC aspirin was not available. The RN stated she notified the DON, and a new order was obtained for a chewable aspirin that was given late. During another observation, an LPN attempted to obtain medications for a resident and found three medications unavailable: Bumex, metoprolol, and citalopram. The LPN checked overflow and reported the missing medications to the Unit Manager; two of the medications were later pulled from the Pyxis after the scheduled time. A separate observation showed the same resident still missing medications that had been unavailable during the prior day’s med pass, and the nurse again reported this to the Unit Manager, who obtained the medications from the Pyxis. Review of the record showed metoprolol was not given on 4/7/2026. Staff interviews indicated that missing medications should be re-ordered, checked in overflow, obtained from the Pyxis, and reported to the DON/pharmacy, and the facility policy stated staff should notify the physician when medication could not be obtained.
Failure to Perform Hand Hygiene During Wound and Foley Care
Penalty
Summary
The facility failed to perform hand hygiene during resident care for one resident who was admitted with diagnoses including cerebral infarction, type 2 diabetes, chronic kidney disease, atherosclerotic heart disease, depression, bipolar disorder, and schizoaffective disorder. The resident’s quarterly MDS indicated severe cognitive impairment, dependence on staff for all ADLs, an indwelling Foley catheter, and bowel incontinence. The care plan identified risk for skin breakdown, an indwelling catheter, a pressure ulcer, and skin breakdown, and physician orders included Foley catheter care every shift and PRN and daily wound care to the sacrum. During observation of wound care, an LPN donned a gown, washed her hands, gathered supplies, and returned to the room. She then performed wound care while repeatedly removing gloves and putting on clean gloves without hand hygiene between several steps, including after removing dirty gloves and before continuing wound care. She also handled the wound dressing materials and completed the dressing change without bringing in a biohazard bag, using the resident’s small trash bag instead. The LPN stated she felt she had done everything correctly, but acknowledged the breaks in hand hygiene when they were pointed out. During observation of Foley catheter care, a CNA washed her hands, donned gown and gloves, and cleaned the resident’s rectal area, then wiped the catheter tubing downward from the meatus without hand hygiene and after changing gloves. The Foley tubing was lying behind the resident rather than over a leg and was not secured with a securement device, and there was no privacy cover on the urine bag. The CNA then turned the resident back and wiped the labia front to back without hand hygiene and without donning clean gloves, then removed her gloves and washed her hands. The CNA required prompting to turn the resident and perform care from the resident’s front and stated she was nervous and could not remember how to properly perform Foley catheter care.
Failure to Protect Resident from Sexual Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a male resident with severe cognitive impairment entered the room of a female resident, who was also severely cognitively impaired, and inappropriately touched her upper thigh while attempting to remove her bed covers. This incident was observed and reported by a CNA, who redirected the male resident back to his room. Both residents had diagnoses including dementia, and the female resident was noted to have a BIMS score indicating severe cognitive impairment. The event was documented in the residents' progress notes and substantiated by the facility's investigation records. The facility's policy on abuse, neglect, exploitation, mistreatment, and misappropriation of resident property states a commitment to preventing abuse. However, the incident demonstrated a failure to protect the female resident from sexual abuse by another resident. The DON and Administrator confirmed the substantiated incident and acknowledged the expectation that all residents should remain free from abuse.
Failure to Respond and Document Care for Severe Hypoglycemia
Penalty
Summary
A resident with a diagnosis of type 2 diabetes mellitus and severe cognitive impairment was admitted to the facility and had a care plan in place for diabetes management, including monitoring for hypoglycemia and following a blood sugar protocol. On the date of the incident, the resident's blood sugar was documented at 45 mg/dl, but there was no documentation of the nurse's response to this low reading in the electronic medical record. The facility's blood sugar protocol required specific interventions for low blood sugar, including administration of oral glucose or IM glucagon and rechecking blood sugar, but the records did not show these steps were followed or documented. Later, the resident was found unresponsive and diaphoretic, with a glucose level of 39 mg/dl. Oral glucose was attempted but the resident was too unresponsive, so IM glucagon was administered. The resident remained poorly responsive and was transferred to the emergency room, where further treatment was required for recurrent hypoglycemia. Interviews with staff revealed a lack of documentation regarding the nurse's actions in response to the low blood sugar, and the interim DON confirmed that the expectation was for staff to follow the blood sugar protocol and notify the physician as required.
Failure to Maintain Kitchen Sanitation and Proper Food Storage
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen and food service areas regarding cleanliness and food storage practices. The kitchen's two convection ovens, deep fat fryer, steamer, storage shelves, and large manual can opener were found with heavy accumulations of dried, burned, or sticky food substances and grease. Food storage containers and lids were stored directly on unclean shelves, and the walk-in refrigerator's shelving units were also unclean. The main dining room's ice machine contained a black mold-like substance, and the microwave oven had a heavy accumulation of dried food spills and debris. These conditions were confirmed by the Dietary Manager and the Administrator during interviews. Additionally, dietary staff failed to properly label, date, and cover food and beverages stored in the kitchen. Unlabeled and undated items included a large pan of Sheppard's pie, cooked broccoli, cups of juice, ham sandwiches, an opened package of ham slices, an opened package of shredded cheese, and an opened bag of lettuce. Bread storage racks contained opened and undated packages of hamburger buns, and a food storage bin held an open, uncovered 25-pound bag of flour. In the walk-in freezer, large bags of frozen potato cakes, a box of biscuits, and a box of chicken tenderloins were stored open and unprotected from contamination. These issues were acknowledged by the Dietary Manager during the inspection. Facility policies required all kitchen and dining areas, equipment, and utensils to be kept clean and sanitized, and for all food products to be labeled and dated appropriately. The observed failures to maintain cleanliness and proper food storage practices were in direct violation of these policies, creating an environment that could potentially affect all residents consuming food prepared in the facility's kitchen.
Infection Control Deficiencies in Laundry Area
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's laundry area related to infection prevention and control. There was a three-fourth-inch gap under the exterior door leading into the soiled laundry area, and a section of wallboard was broken with exposed insulation, where pillows were found resting against the insulation. The air vents in the soiled laundry room had visible debris buildup, and exposed steel beams were present. Additionally, the opening between the sorting area and the washing machine room was trimmed with unfinished molding, making the surface uncleanable. Further observations revealed that the floor near the washing machines had heavy debris accumulation, including on the floor and on plastic crates supporting laundry chemical buckets. Reusable rubber gloves were found on the floor behind a bucket of chemicals next to the washing machine. In the drying area, a standing floor fan had heavy debris buildup on its grate. The Laundry Supervisor confirmed the need for repairs and cleaning in these areas.
Failure to Serve Palatable and Hot Food to Residents
Penalty
Summary
The facility failed to serve food that was palatable and at a safe, appetizing temperature to four cognitively intact residents. Multiple residents reported that their meals, particularly breakfast, were served cold, with specific complaints about cold eggs, breakfast meat, and grits. These residents typically ate their meals in their rooms and consistently noted that hot foods were not served at an appropriate temperature. The facility's policies required hot foods to be held at 136 degrees Fahrenheit or above and cold foods at 40 degrees or below until served, with procedures in place for monitoring food temperatures and quality. Observation during a test tray audit confirmed that while food temperatures were acceptable when leaving the kitchen, the meals were served on unheated plates and transported on a cart without a heating element. By the time the last tray was served, the food had become cold, as confirmed by both a surveyor and an LPN who tasted the test tray items. The Dietary Manager acknowledged that the plate warmer was not in use due to a broken suction cup and that available insulated plate holders were not utilized by staff during the meal service.
Failure to Assess Resident Before Allowing Self-Administration of Medications
Penalty
Summary
The facility failed to assess a resident for self-administration of medications before medications were left at the bedside. According to the facility's policy, an interdisciplinary team assessment is required to determine a resident's ability to self-administer medications. The resident in question had diagnoses including dementia, anxiety disorder, hypertension, and major depressive disorder, and was documented as being severely cognitively impaired with a BIMS score of three out of 15. There were no physician orders or care plan documentation permitting the resident to self-administer medications. The Assistant Director of Nursing confirmed that the resident was not able to self-administer medications after the resident's sister found a cup of pills on the nightstand in the resident's room.
Failure to Notify Responsible Party of New Medication Order
Penalty
Summary
The facility failed to notify the responsible party (RP) of a resident with severe cognitive impairment about a new medication order prior to its administration. The resident, who was admitted with diagnoses of dementia and anxiety disorder and had a BIMS score of zero, was prescribed Naltrexone 50 mg daily for obsessive-compulsive disorder (OCD) related behaviors. Documentation in the electronic medical record and nursing progress notes did not show that the RP was informed of the new medication order before it was given. Interviews with the Assistant Director of Nursing (ADON) and Interim Director of Nursing (IDON) confirmed that the nurse responsible for the order did not notify the RP as required. The ADON only became aware of the omission after reviewing the record at a later date. Both the ADON and IDON acknowledged that the RP should have been notified and that this should have been documented in the resident's medical record.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, as required by its Abuse Prevention Program policy. According to the report, two residents with significant cognitive and psychiatric diagnoses, including metabolic encephalopathy, anxiety disorder, bipolar disorder, and depression, were involved in a physical altercation. The incident involved both residents hitting each other in the arm. The facility's policy specifically states that residents must be protected from abuse by anyone, including other residents, and defines physical abuse as actions such as hitting and slapping. A review of the electronic medical record showed that one of the residents involved had a severely impaired mental status, with a BIMS score of six out of 15. Following the altercation, skin assessments indicated that neither resident sustained redness, discoloration, or open areas. Interviews with facility staff confirmed that the residents were immediately separated after the incident, and both residents blamed each other for the altercation. The report documents that the facility did not prevent the physical abuse from occurring between the two residents.
Failure to Promptly Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to ensure that an allegation of abuse was reported promptly to the abuse coordinator/administrator and the State Agency (SA) as required by facility policy. A resident with severe cognitive impairment, as indicated by a BIMS score of 2 out of 15 and diagnoses of dementia and anxiety, reported to an agency LPN that they felt they had been raped. This report was made during the early morning hours, but the facility's records show that the SA was not notified until several days later. Facility policies required immediate reporting of such allegations to both the abuse coordinator/administrator and the SA, but this did not occur. The delay in reporting resulted in the allegation not being investigated in a timely manner.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, as required by its own policy and regulatory standards. For one resident with a diagnosis of dementia and a moderately impaired cognitive status (BIMS score of 12/15), there was no documentation of a dementia care plan in the electronic medical record. This omission was confirmed by an LPN, who stated that the care plan was likely overlooked due to the resident's relatively high BIMS score and a failure to review the diagnosis during the MDS process. For another resident with severe cognitive impairment (BIMS score of 4/15), dementia, and type 2 diabetes, the care plan did not reflect a newly identified sacral wound that was discovered and treated on a specific date. The wound was measured, cleansed, and treated per physician notification, but the care plan was not updated to include this new condition. An LPN confirmed that the care plan should have included this information to address the resident's current needs.
Failure to Thoroughly Investigate Resident Fall
Penalty
Summary
The facility failed to thoroughly investigate a fall experienced by a resident diagnosed with Huntington's Disease, who had both short-term and long-term memory loss and was severely impaired in cognitive skills for daily decision-making. The resident, identified as being at risk for falls due to Huntington's Disease and decreased mobility, slid off the edge of the bed onto the floor while being changed by a CNA. The care plan included education for the resident, family, or caregiver about safety reminders and fall response. However, the Assistant Director of Nursing (ADON) completed the investigation report solely by reviewing the nurse's documentation and did not obtain statements from the CNA or nurse present at the time of the fall, stating she was unaware this was required. This lack of a comprehensive investigation had the potential for the fall not to be thoroughly reviewed, which could allow for repeated incidents.
Failure to Complete Dialysis Communication Forms for Resident Receiving Dialysis
Penalty
Summary
The facility failed to complete required Dialysis Communication Forms for a resident with end-stage renal disease (ESRD) who received dialysis treatments at an outside center. According to facility policy, staff are expected to document and exchange information regarding the resident's care and medication administration through these forms, which are to be completed by both the facility and the dialysis center for each treatment. Review of the resident's electronic medical record and Dialysis Communication Notebook revealed that these forms were not completed on multiple specified treatment dates. Interviews with the resident, the Assistant Director of Nursing (ADON), and the Director of Nursing (DON) confirmed that the process for communication was not followed as required, with the DON stating that nursing staff were expected to complete the forms for each dialysis session. The Registered Nurse Consultant (RNC) also verified that the forms were missing for the listed dates. The resident was cognitively intact and had a care plan in place for ESRD and acute kidney failure, requiring dialysis and medications, but the lack of completed communication forms indicated a failure to ensure effective communication and documentation regarding her dialysis care.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent during medication administration, resulting in an observed error rate of eight percent. During a medication pass, an LPN administered the incorrect doses of two medications to a resident. Specifically, the resident, who had a history of gout and schizoaffective disorder and was cognitively intact, was prescribed Allopurinol 200 mg daily and Seroquel 200 mg twice daily with an additional 400 mg at bedtime. However, the LPN gave only 100 mg of Allopurinol instead of the ordered 200 mg, and administered the 400 mg bedtime dose of Seroquel during the morning medication pass instead of the prescribed 200 mg dose. The errors were confirmed by both the LPN and the Assistant Director of Nursing during interviews. The facility's policy on medication administration, which requires verification of the right resident, medication, dosage, time, and route, was not followed in this instance. The observed failures directly contributed to the medication error rate exceeding the acceptable threshold.
Failure to Follow Planned Menus for Diabetic Resident
Penalty
Summary
The facility failed to follow its planned menus and ensure that a resident with diabetes mellitus received the specified food items as indicated on their meal tray slips. Specifically, the resident was not served cereal at breakfast on multiple occasions, despite the tray slips and planned menus indicating that cereal should have been provided. The resident reported not always receiving cereal as specified, and direct observations confirmed that cereal was missing from the resident's breakfast trays on at least two separate days. The resident also expressed feeling hungry and wanting cereal, which was not provided. Interviews with staff, including a CNA and the Dietary Manager, confirmed that the resident's tray slips called for cereal, and that the kitchen was responsible for ensuring the correct items were served. The Dietary Manager acknowledged that the resident should have received grits or cold cereal according to the menu and tray slips, but this did not occur. The facility's policy required that meals meet residents' nutritional needs and follow the planned menus, but this was not adhered to in the case of this resident, potentially affecting the nutritional intake of all residents receiving meals from the kitchen.
Failure to Consistently Provide Bedtime Snacks to Diabetic Residents
Penalty
Summary
The facility failed to provide a bedtime snack each night for three diabetic residents, despite physician orders and facility policy requiring such snacks for insulin-dependent diabetics. Review of records showed that two of the residents were cognitively intact and one had moderate cognitive impairment. All three residents reported not consistently receiving their prescribed bedtime snacks, with some stating they only received snacks a few times per week. Physician orders for bedtime snacks were present for at least two of the residents, and all three expressed a desire to receive a nightly snack as part of their care. Interviews with staff revealed that the kitchen did not always provide enough snacks for all residents who required them, and snacks were not consistently labeled with resident names, particularly for diabetic residents. Certified Nursing Assistants reported that the kitchen sometimes failed to send enough snacks, and the Dietary Manager confirmed that all diabetic residents should receive a nightly snack, with snacks to be labeled and delivered accordingly. Facility policy also indicated that residents should have access to nourishing snacks throughout the day and night, but this was not consistently implemented.
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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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