Chulio Hills Health And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Rome, Georgia.
- Location
- 1170 Chulio Road, Rome, Georgia 30161
- CMS Provider Number
- 115287
- Inspections on file
- 18
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Chulio Hills Health And Rehab during CMS and state inspections, most recent first.
Surveyors found that the facility did not maintain a clean and safe environment, with dust-like buildup on ceiling vents and unrepaired ceiling tiles in several halls and common areas. The Administrator, ADON, and DON confirmed the dust accumulation, which could trigger respiratory issues in residents with pre-existing conditions. The Maintenance Director stated that vent cleaning was scheduled quarterly but had not identified the issue during daily rounds.
A resident with multiple medical conditions and recent weight loss began refusing meals and medications, representing a significant change in status. Despite facility policy requiring prompt notification, neither the responsible party nor the Registered Dietician were informed of these ongoing refusals. Staff interviews confirmed the change was new and significant, but documentation and communication to all relevant parties did not occur.
A resident receiving hospice care was not accurately coded as such on the Quarterly MDS assessment, as required. Review of facility policy revealed it did not provide guidance for accurate coding of hospice services, and staff interviews confirmed the omission, which affected the accuracy of the resident's care plan.
A resident with multiple respiratory diagnoses and severe cognitive impairment did not have a care plan addressing oxygen use or respiratory conditions, despite physician orders and MDS documentation indicating the need for oxygen therapy. Staff confirmed the omission and acknowledged the importance of accurate care planning for directing resident care.
A resident with multiple complex medical conditions and severe cognitive impairment, who was fully dependent for care and bed-bound, developed a pressure ulcer during a respite stay. The facility failed to consistently assess, monitor, and document the resident's skin condition, and did not provide or document required wound care after a pressure ulcer was identified, despite physician orders and facility policy requiring such interventions.
A resident with respiratory failure and CHF was not provided oxygen therapy at the physician-ordered rate of 2 LPM via nasal cannula. Observations and staff interviews confirmed the oxygen concentrator was set below the prescribed rate, contrary to facility policy and physician orders. Nursing staff did not ensure the correct flow rate was maintained.
Two residents were not instructed to rinse and spit after receiving corticosteroid inhalers, resulting in a medication error rate above 5%. LPNs failed to follow facility policy and manufacturer instructions, despite clear labeling on the medication packaging. Interviews confirmed staff awareness of the requirement, but the step was omitted during observed medication passes.
A resident with a history of stroke and difficulty eating was not consistently provided with physician-ordered built-up utensils at mealtimes, despite clear documentation and facility policy. The resident often had to request the adaptive equipment from staff, resulting in delays and cold food, as observed and confirmed by staff interviews.
Staff failed to follow infection prevention protocols, including an LPN removing a glove box from a resident's room after wound care and a maintenance assistant not using PPE or performing hand hygiene when exiting a Contact Precautions room for candida auris. The facility also did not review or update its Infection Prevention and Control Program policy annually as required.
The facility failed to maintain an adequate Surety Bond to cover the resident trust fund account balance for three months. The bond was set at $80,000.00, while the account balances exceeded this amount in February, May, and July 2024. The Administrator confirmed the discrepancy and was unsure why the bond amount was not adjusted. The bond amount was based on past balances as recommended by the bond company, potentially affecting 62 residents.
The facility failed to ensure the Dietary Manager was certified in dietary or food service management, as required by policy and CMS guidelines. The DM, promoted from a dietary cook, lacked necessary certifications, although she was in the process of obtaining them. The Administrator expected the DM to obtain Serve Safe certification and eventually become a Certified Dietary Manager, but this had not been achieved. The facility did not use a DM from sister facilities for oversight, and the Registered Dietitian provided monthly guidance.
The facility failed to label and date food items in the dry storage and resident nourishment room, leading to unlabeled grits and resident food items. Ice build-up was found on open strawberries in the walk-in freezer. Additionally, improper sanitization procedures were observed, with dishware submerged for less time than required in the sanitizing solution.
The facility failed to implement a 14-day stop date for psychotropic medications for four residents, as required by its policy. Residents were administered lorazepam and Ativan without a documented stop date, leading to a deficiency in medication management. Despite daily reviews of new orders, the oversight occurred, and the DON acknowledged the error, stating that medications should have been reassessed before reordering.
A facility failed to refer a resident with anxiety and depressive disorders for a PASARR level two review, as required by policy. The resident was cognitively intact and on anti-anxiety and antidepressant medications. The Social Service Director did not resubmit the PASARR, believing it unnecessary due to the primary diagnosis not being a mental health issue. The Administrator expected reviews for major mental health diagnoses, but this was not done, leading to a deficiency.
A medication cart was found unlocked and unattended in a hallway, accessible to residents and unauthorized individuals. The responsible RN acknowledged the oversight, and the facility's policy requires carts to be locked when unattended. The DON noted uncertainty about night shift staff receiving relevant education.
A CNA failed to follow infection control protocols for a resident on Enhanced Barrier Precautions (EBP) due to an indwelling catheter. The CNA used the same washcloth for different body areas and did not change the basin water, contrary to facility policy. Additionally, the CNA did not wear a gown as required, despite signage and training indicating the need for PPE during high-contact care activities.
Failure to Maintain Clean and Safe Environment Due to Dust Accumulation and Damaged Ceiling Tiles
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, functional, sanitary, and comfortable environment in multiple areas, including the 100, 200, and 300 Halls, the common area near the nurse station, and the lobby. Specifically, there was a delay in repairing damaged ceiling tiles and a noticeable accumulation of dust-like material on ceiling vents. The facility's policy on cleaning and disinfection required regular cleaning of environmental surfaces and wet dusting of horizontal surfaces with EPA-registered disinfectant, but these standards were not met as evidenced by the visible dust and unrepaired ceiling damage. During interviews and observations with the Administrator, ADON, and DON, all confirmed the presence of dust accumulation on vents throughout the facility, acknowledging that such buildup could provoke allergic reactions and respiratory distress in residents with pre-existing respiratory conditions. The Maintenance Director reported that vent cleaning was scheduled every three months and monitored through the TELS system, but admitted he had not noticed the dust accumulation during his daily rounds. No specific residents were identified as being directly affected at the time of the deficiency.
Failure to Notify Responsible Party and Dietician of Significant Change in Resident Condition
Penalty
Summary
The facility failed to notify the responsible party and the Registered Dietician (RD) of a significant change in a resident's condition, specifically regarding ongoing refusals of meals and medications. The resident, who had a history of hypertension, cognitive impairment, dysphagia, chronic kidney disease, and recent abnormal weight loss, began refusing meals and medications over several days. Documentation showed that the resident consumed less than 25% of meals or refused them entirely on multiple occasions, and also refused several doses of prescribed medications. Despite these changes, there was no documentation that the resident's representative or the RD were informed of the ongoing refusals and significant change in status. Staff interviews confirmed that the resident's behavior of refusing meals and medications was new and represented a significant change from previous patterns. The LPN stated that refusals were documented and the physician was notified, but the RD was not informed. The RD herself confirmed she was unaware of the refusals and would have reassessed the resident's nutritional plan had she been notified. The resident's representative also reported not being informed about the refusals and was unaware of the change in the resident's condition until contacted by surveyors. Facility policy required prompt notification of the resident, physician, and representative of significant changes in condition, including those requiring alterations in treatment. However, interviews with staff, including the MDS RN, Infection Preventionist/Unit Manager, DON, and Administrator, revealed inconsistent understanding and application of these policies. The lack of notification to the RD and responsible party was not documented, and staff acknowledged the importance of such communication but failed to ensure it occurred in this case.
Quarterly MDS Assessment Failed to Reflect Hospice Services
Penalty
Summary
The facility failed to accurately complete the Quarterly Minimum Data Set (MDS) assessment for one resident who was receiving hospice services. Review of the facility's policy on Maintaining Minimum Data Set (MDS) Assessments showed that it addressed record maintenance and retention but did not provide guidance to ensure accurate coding of services, such as hospice care, on Quarterly MDS assessments. The electronic medical record indicated that the resident was admitted to hospice services, but the corresponding Quarterly MDS assessment did not reflect this in section O, which covers Special Treatments, Procedures, and Programs. Staff interviews confirmed that hospice services were not coded on the assessment, and both the MDS RN and DON acknowledged the importance of accurate MDS coding for care planning.
Failure to Develop and Implement Comprehensive Care Plan for Oxygen Use
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for one resident with multiple respiratory diagnoses, including Alzheimer's Disease, COPD, respiratory failure, asthma, and heart failure. Despite the resident's Minimum Data Set (MDS) assessment indicating severe cognitive impairment and the need for oxygen therapy, the care plan did not include any problems or interventions related to respiratory conditions or oxygen use. Physician's orders documented the need for oxygen administration at 2 L/min via nasal cannula, weekly changes of oxygen tubing, weekly cleaning of the oxygen concentrator filter, and elevating the head of the bed for shortness of breath, but these were not reflected in the care plan. Observations confirmed that the resident was using oxygen as ordered, but interviews with the resident revealed uncertainty about the frequency of oxygen use. Staff interviews, including with the MDS RN and DON, confirmed that the care plan was missing required information regarding oxygen use and respiratory diagnoses. The MDS RN acknowledged that the omission was an oversight and emphasized the importance of accurate MDS coding for care planning. The DON also confirmed that the care plan should direct all aspects of resident care and must be accurate.
Failure to Prevent and Treat Pressure Ulcer in High-Risk Resident
Penalty
Summary
The facility failed to ensure that appropriate pressure ulcer prevention interventions were initiated, implemented, monitored, and documented for a resident identified as being at risk for pressure injuries, who developed a pressure ulcer during their stay. The facility's policy required comprehensive skin assessments upon admission and weekly for four weeks, as well as head-to-toe skin observations during showers and regular repositioning for bed-bound residents. However, documentation revealed that only limited skin assessments were completed during the resident's five-day respite stay, with no evidence of consistent monitoring or timely intervention when skin changes were noted. The resident in question was admitted for respite care with multiple complex medical conditions, including morbid obesity, acute respiratory failure, chronic heart failure, peripheral vascular disease, and severe cognitive impairment. The care plan indicated the resident was bed-bound, fully dependent for all activities of daily living, and required total assistance with bed mobility and self-care. Despite these risk factors, the electronic medical record showed that only two skin assessments were documented, and there was no evidence of regular repositioning or implementation of other pressure ulcer prevention measures as outlined in the facility's policy. When a pressure ulcer was identified on the resident's left heel, a physician's order for wound care was written, but there was no documentation that the treatment was provided or that the order was carried out. Interviews with staff confirmed that wounds should be reported and treated promptly, but no treatment notes or interventions were found in the record. Additionally, there was no documentation of care plan updates or evidence that staff addressed difficulties with repositioning the resident, despite reports of such challenges. This lack of assessment, intervention, and documentation contributed to the development and lack of treatment for the pressure ulcer.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
A deficiency was identified when a resident with a history of respiratory failure, hypoxia, pneumonia, and congestive heart failure was not administered oxygen therapy in accordance with the physician's orders. The resident's care plan specified continuous oxygen via nasal cannula at 2 liters per minute (LPM). However, multiple observations revealed that the oxygen concentrator was set below the prescribed 2 LPM, with flow rates recorded between 1.5 and 2 LPM. Staff interviews confirmed that the oxygen flow was not consistently set to the ordered rate, and the concentrator's marker was not properly aligned with the prescribed setting. Facility policy required nurses to initiate oxygen use as ordered, label tubing, and ensure orders for filter cleaning and humidification were entered into the system, as well as to check oxygen saturations as ordered by the physician. Despite these requirements, staff did not ensure the oxygen concentrator was set to the correct flow rate. Both the ADON and DON acknowledged that the oxygen was not set according to the physician's order and that nurses are responsible for monitoring and adjusting concentrators as needed.
Failure to Ensure Proper Administration of Corticosteroid Inhalers
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required by policy and manufacturer instructions. During 35 observed medication administration opportunities, two medication errors were identified, resulting in a 5.71% error rate. Specifically, during two separate medication passes, nursing staff did not instruct residents to rinse and spit after administering corticosteroid inhalers, despite clear facility policy and manufacturer instructions requiring this step. Both inhaler boxes had bright green notes stating, "Rinse mouth thoroughly after each use," but this directive was not followed during the observed administrations. Interviews with the involved LPNs revealed uncertainty and forgetfulness regarding the requirement to provide water and instruct residents to rinse and spit after inhaler use. The pharmacist confirmed that rinsing the mouth after using inhaled corticosteroids is necessary to prevent oral candidiasis and stated that staff were alerted to this requirement through labeling on the medication packaging. The DON and ADON also acknowledged that mouth rinsing is recommended for steroid inhalers and that staff were expected to encourage this practice, as indicated on the medication packaging.
Failure to Provide Required Feeding Adaptive Equipment at Meals
Penalty
Summary
Staff failed to provide a resident with the required feeding adaptive equipment at each meal, despite a physician's order and clear documentation on the resident's meal card indicating the need for built-up utensils. The resident, who had a history of stroke and significant difficulty eating without adaptive equipment, reported that the specialized utensils were usually missing from her meal tray. On multiple observed occasions, the resident's tray was delivered without the necessary adaptive device, and she had to request assistance from a CNA to obtain it, resulting in her food becoming cold before she could eat. Review of facility policy confirmed that residents should be assessed for adaptive equipment and provided with it as needed to facilitate independence. Interviews with the Dietary Manager and Administrator confirmed that there were sufficient devices available and that staff were expected to provide them when ordered by a physician. However, observations and interviews demonstrated that the process was not consistently followed, leading to the resident not receiving the required adaptive equipment at mealtimes.
Failure to Maintain Infection Control Practices and Policy Review
Penalty
Summary
The facility failed to maintain appropriate infection prevention and control practices as evidenced by multiple observed breaches and lack of policy review. During wound care, an LPN brought a full box of gloves into a resident's room, used gloves from the box, and then removed the same box for use with other residents, despite acknowledging that this practice could create a contamination risk. Additionally, a maintenance assistant exited a room under Contact Precautions for candida auris without wearing required PPE (gown or gloves) and did not perform hand hygiene after leaving the isolation room. The assistant also indicated a lack of knowledge regarding infection prevention protocols and had not received relevant training. Further review revealed that the facility's Infection Prevention and Control Program policy, last revised in October 2018, had not been reviewed or updated annually as required by the facility's own policy. Staff interviews confirmed that all personnel are expected to adhere to PPE and hand hygiene protocols, and that glove boxes used in resident rooms should not be removed to prevent cross-contamination. These failures were identified through observations, staff and resident interviews, and record review.
Inadequate Surety Bond Coverage for Resident Trust Funds
Penalty
Summary
The facility failed to maintain a Surety Bond in an adequate amount to cover the resident trust fund account balance for three of the six months reviewed. The Surety Bond was set at $80,000.00, which was insufficient to cover the ending balances of the resident trust fund account for February, May, and July 2024, which were $92,715.87, $93,849.05, and $95,520.15, respectively. This discrepancy was identified through a review of the facility's bank statements and the facility's policy titled 'Resident Trust Fund Accounting Policies and Procedures.' The Administrator confirmed the Surety Bond amount and the resident trust fund balances during an interview. She expressed uncertainty as to why the bond amount was not adjusted to exceed the highest monthly balance. The facility's Corporate Human Resources had based the bond amount on the resident trust fund balances from August 2021 to January 2022, as recommended by the bond company. This oversight had the potential to adversely affect the finances of 62 residents with trust fund accounts managed by the facility.
Deficiency in Dietary Manager Certification
Penalty
Summary
The facility failed to ensure that the staff designated as the Dietary Manager (DM) was certified in dietary or food service management, as required by their policy and CMS guidelines. The DM, who was promoted from a dietary cook position, did not possess any dietary certifications at the time of the survey. Although the DM was in the process of obtaining certification, she had not yet completed the necessary test. The facility policy required the DM to maintain current Serve Safe Food Handler certification and obtain Certified Dietary Manager (CDM) certification, which had not been fulfilled. The Administrator acknowledged that there was an expectation for the DM to at least obtain the Serve Safe Food Manager certification and eventually become a Certified Dietary Manager. However, the facility was not utilizing a DM from any sister facilities to assist with dietary oversight. The Registered Dietitian visited the facility once a month to provide dietary guidance, but the lack of a certified DM on staff at the time of the survey constituted a deficiency in meeting the required standards for food and nutrition services.
Deficiencies in Food Labeling, Storage, and Sanitization Procedures
Penalty
Summary
The facility failed to adhere to its policies regarding food labeling and storage, as well as proper sanitization procedures, leading to several deficiencies. In the dry storage area, an opened five-pound bag of grits was found without an open date, which was confirmed by the Dietary Manager (DM) as a failure to follow the facility's policy. In the walk-in freezer, an open case of frozen strawberries was observed with ice build-up on top, which the DM acknowledged was due to the air condenser's issues and confirmed that dietary staff had been removing the ice as needed. Additionally, in the resident nourishment room, several food items, including Styrofoam containers and frozen pizzas, were found without resident names or dates, which the DM and Administrator confirmed was the responsibility of the nursing staff, who had been previously educated on this requirement. Furthermore, the facility did not demonstrate proper sanitization procedures in the three-compartment sink. The dietary cook was observed submerging dish items in a quaternary sanitizing solution for only 20-30 seconds, contrary to the posted instructions that required at least one minute of immersion. The DM confirmed the discrepancy between the cook's practice and the posted guidelines, acknowledging that the dietary staff should have adhered to the one-minute immersion time as indicated by the posters above the sink.
Failure to Implement Stop Dates for Psychotropic Medications
Penalty
Summary
The facility failed to implement a stop date not exceeding 14 days for psychotropic medications for four residents, leading to a deficiency in medication management. The facility's policy requires that PRN orders for psychotropic drugs are limited to 14 days unless the prescribing practitioner documents a rationale for extending the order. However, the review of medical records revealed that residents were administered lorazepam and Ativan without a documented stop date, contrary to the facility's policy. Interviews with the Director of Nursing (DON) and Licensed Practical Nurse (LPN) Unit Managers indicated that the oversight occurred despite daily reviews of new medication orders. For instance, one resident had an order for lorazepam with an indefinite end date and was administered the medication multiple times over a month. Another resident had a similar order for lorazepam for agitation, also without a stop date, and was administered the medication on several occasions. The DON acknowledged the lack of stop dates and stated that the medication should have been reassessed before reordering. The facility's failure to adhere to its policy on psychotropic medication orders resulted in the deficiency identified by the surveyors.
Failure to Refer Resident for PASARR Level Two Review
Penalty
Summary
The facility failed to refer a resident for a preadmission screening and resident review (PASARR) level two, as required by their policy. The resident, identified as R33, was admitted with diagnoses including general anxiety disorder and major depressive disorder. Despite these diagnoses, the facility did not resubmit a PASARR for a level two review. The facility's policy mandates that any resident with a newly evident or possible serious mental disorder, intellectual disability, or related condition should be referred for a level two review. However, the Social Service Director did not believe a level two PASARR was necessary for R33, as the primary diagnosis was not considered a mental health diagnosis. Observations of R33 showed that she was cognitively intact, with no signs of depression or psychosis, and was receiving anti-anxiety and antidepressant medications. Interviews revealed that the facility was in the process of changing mental health service providers, and R33 was not currently receiving psychiatric services. The Administrator stated that the expectation was for the Social Service Director to review each resident's diagnosis and resubmit the PASARR for a level two review if a major mental health diagnosis was present. The failure to obtain a level two PASARR for R33 was identified as a deficiency, potentially placing the resident at risk for improper placement and inadequate mental health care.
Unattended Medication Cart Found Unlocked
Penalty
Summary
The facility failed to ensure that one of three medication carts was locked and secured when left unattended by a nurse, as observed during an initial tour. The medication cart was found unlocked and unattended in a hallway, with its drawers facing the hallway, making it easily accessible to residents, unauthorized staff, and visitors. A registered nurse (RN) responsible for the cart walked by it twice without securing it, and a resident was observed self-propelling past the cart. Upon being interviewed, the RN acknowledged the cart was unlocked and unattended but declined further comment. The facility's policy on medication storage requires that medication carts be locked or attended by authorized personnel. Interviews with the Administrator and the Director of Nursing (DON) confirmed that the expectation was for medication carts to be locked when unattended. The DON mentioned that a pharmacy consultant conducted random audits and provided monthly education to nursing staff, but there was uncertainty about whether night shift nurses received this education. The failure to lock the medication cart increased the risk of unauthorized access to medications.
Infection Control Breach During Resident Care
Penalty
Summary
The facility failed to adhere to proper infection control techniques while providing care to a resident on Enhanced Barrier Precautions (EBP). The facility's policy required staff to change the basin water, use a clean washcloth, perform hand hygiene, and don new gloves after washing and before rinsing the resident. Additionally, the policy specified that cleaning should begin at the face and work over the body, with the groin and buttocks cleaned last. However, during an observation, a Certified Nursing Assistant (CNA) did not follow these guidelines. The CNA used the same washcloth to clean the resident's catheter site, groin area, and entire front body, and used the same basin of water for washing and rinsing. Furthermore, the CNA did not don a gown while providing the resident with a bed bath, incontinent care, linen change, and dressing, despite the resident being on EBP due to an indwelling catheter. The CNA admitted to not wearing a gown and was unaware of the requirement to use PPE when caring for residents with Foley catheters, feeding tubes, PICC lines, or IVs. The CNA also stated she did not see the sign on the resident's door indicating EBP and had never read it. The Infection Control Preventionist (ICP) confirmed that staff were expected to wear gowns and gloves when providing care to residents on EBP and that all staff had received training on EBP. The ICP also stated that signs were posted on residents' rooms indicating the required PPE. Despite this, the CNA did not follow the proper procedures, leading to a potential risk of spreading infection within the facility.
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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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