Crestview Health & Rehab Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Atlanta, Georgia.
- Location
- 2800 Springdale Road, Atlanta, Georgia 30315
- CMS Provider Number
- 115525
- Inspections on file
- 25
- Latest survey
- March 1, 2026
- Citations (last 12 mo.)
- 9 (3 serious)
Citation history
Health deficiencies cited at Crestview Health & Rehab Ctr during CMS and state inspections, most recent first.
Multiple residents with varying levels of cognitive impairment experienced sexual and physical abuse or inappropriate contact by other residents and by a CNA, including alleged sexual touching, an observed oral sex act, a resident slapping another resident, unwanted touching in a resident’s room, breast pinching, and a resident being forcibly moved and striking his head on a doorframe. Although some events were documented in progress notes and one resident was sent to the hospital, the facility did not complete thorough investigations, did not promptly perform or document physical and psychosocial assessments, and did not revise care plans or implement clear protective interventions and monitoring to prevent further abuse, contrary to its own abuse prevention policy.
The facility failed to conduct thorough investigations into multiple allegations of physical and sexual abuse involving several residents with cognitive impairment, psychiatric conditions, and complex medical histories. In numerous cases, police were notified and case numbers obtained, but there was no follow-up with law enforcement, no or limited interviews with other residents or staff who might have witnessed or known about the incidents, and no timely physical or psychosocial assessments of the involved residents. This pattern included resident-to-resident physical altercations, alleged sexual contact between residents, and an allegation that a CNA forcefully moved a resident, causing a head injury, as well as a complaint that an LPN attempted to force medication and struck a resident with a remote. The Manager of Quality/Risk and the Administrator acknowledged that investigations were incomplete and did not meet the facility’s own abuse policy requirements for identifying and interviewing all involved persons and thoroughly documenting investigations.
Administration failed to implement abuse policies and procedures and did not ensure thorough investigations after multiple residents reported physical and sexual abuse by staff and other residents. Incidents included a resident being grabbed and thrown against a doorframe by staff, resulting in a laceration, several residents reporting inappropriate touching or sexual abuse by other residents, and one resident slapping another in the face without provocation. The Administrator and DON acknowledged that the facility lacked policies and procedures to guide staff in identifying, reporting, investigating, and preventing abuse, despite the Administrator’s responsibility to assure care that promotes quality, safety, and respect.
Surveyors found that the facility did not properly obtain or document informed consent for psychotropic medications for three residents. One resident with dementia and behavioral disturbances was receiving Depakote ER for mood and agitation without any signed consent or documented risks vs benefits. A second cognitively intact resident with multiple psychiatric diagnoses was on four psychoactive medications (Klonopin, Abilify, Sertraline, Quetiapine); although a consent form was signed and witnessed due to the resident’s physical limitations, the form lacked required details such as specific drugs, dosages, frequencies, targeted behaviors, and potential side effects. A third severely cognitively impaired resident with dementia and other psychiatric conditions was receiving Valproate Sodium for behaviors without any signed consent or documented discussion of risks and benefits. The DON acknowledged that consents for these residents could not be located, despite a facility policy requiring such information and documentation before initiating or increasing psychotropic medications.
A resident with quadriplegia and idiopathic hypotension, who was cognitively intact, requested assistance in obtaining a Social Security card and a Georgia ID. Social services documented attempts to complete Social Security forms and discussed the issue with the resident’s out-of-state representative, who had health issues and relied on facility staff for help. An application for a Social Security card was completed, but there was no documented follow-up for more than three and a half months, and the resident never received the card or ID. During interviews, the resident and representative confirmed the documents were never obtained and described the situation as very stressful, while social services staff acknowledged that no follow-up occurred and that assisting with such matters was their responsibility under facility policy.
The facility did not ensure that residents were protected from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any person.
The facility failed to protect a resident from the wrongful use of their belongings or money, resulting in a deficiency related to safeguarding personal property and financial resources.
Surveyors found that a resident did not receive an accurate assessment, as required, due to incomplete or inaccurate documentation of their condition or needs.
A facility failed to provide required one-to-one supervision for four residents with severe cognitive impairments, as outlined in their care plans. This neglect was identified through observations and interviews, revealing that night shift CNAs were not informed of the supervision requirements and were assigned additional residents, compromising care. One resident was found on the floor and sent to the hospital, highlighting the facility's failure to adhere to its policy on abuse, neglect, and exploitation.
Failure to Protect Residents From Abuse and Implement Protective Interventions After Allegations
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from abuse and to implement adequate actions and care plan interventions after abuse allegations. One cognitively intact male resident with a history of verbal and sexual aggression toward staff was care planned for potential sexually abusive behavior, but his care plan and record contained no specific behavioral monitoring or interventions after two separate sexual abuse allegations by two cognitively intact female residents. One of these residents reported that he rubbed her inner thigh and hair in a way that made her feel violated, and documentation showed he was moved to another unit due to her allegation, yet there was no evidence of immediate physical or psychosocial assessment of her after the incident. The other resident reported being raped by this same male resident, was sent to the hospital, and refused examination, but her care plan did not show ongoing interventions to prevent further abuse by him. Another incident involved a male resident allegedly performing oral sex on his cognitively intact male roommate. A CNA discovered the roommate in bed with his penis exposed and the other resident bent over him, moving in an up‑and‑down motion. Progress notes documented that the social worker spoke with both residents three days later, but there was no evidence of an immediate physical assessment or timely psychosocial assessment of either resident to rule out physical or psychosocial harm. The care plans for both residents lacked any problem or interventions related to this sexual incident or measures to prevent further sexual abuse. Observations later showed the alleged perpetrator alone in a private room, rarely leaving his room and requiring extensive assistance, but there was no documentation of specific monitoring or protections related to the prior allegation. The facility also failed to adequately address physical abuse and inappropriate contact among other residents and by staff. One severely cognitively impaired resident with known behavioral issues had previously been placed on 1:1 care after attempting to hit staff and then hitting another resident, yet her care plan did not address a later incident in which she slapped another cognitively impaired resident in the face when redirected from striking staff. Although a progress note documented that no injuries were noted and the situation was de‑escalated, the investigation file was incomplete. In separate cases, a moderately impaired resident reported through a family member that another severely impaired resident entered her room and touched her body, and a cognitively intact resident was observed being pinched on the breast by another cognitively impaired resident, causing her to yell out. The investigative files confirmed these reports but did not show that care plans were updated or that protective measures were implemented. In addition, a severely cognitively impaired resident with Alzheimer’s disease sustained a head laceration when a CNA, while providing personal care with another aide present, grabbed the resident by the sweater, jerked him from a seated position, and swung him toward the bathroom after he refused care, causing his head to hit the doorframe. A nurse entered the room and witnessed the CNA swinging the resident and the impact with the doorframe. The facility’s Manager of Quality/Risk Manager, who conducted most abuse investigations, confirmed that the facility’s investigative materials for all of these incidents were incomplete and that abuse was substantiated only in the case of the physical abuse by one resident against another. She and the Administrator acknowledged there was no documentation of prompt resident assessments, care plan updates, or adequate measures to prevent further abuse by the involved residents and the CNA, despite facility policies requiring immediate protection, examination, psychosocial assessment, room or staffing changes, emotional support, and care plan revision after incidents of abuse.
Failure to Conduct Thorough Abuse Investigations
Penalty
Summary
The deficiency involves the facility’s failure to conduct thorough investigations into multiple allegations of abuse, including physical and sexual abuse, involving numerous residents. For several incidents, the facility notified local law enforcement and obtained case numbers but did not follow up with the police department to obtain information about their investigations. In the cases involving a resident with a history of stroke who alleged being punched by another resident, later alleged sexual touching by a male resident, and was involved in a separate altercation with another resident who threw items at her, the facility’s investigative files lacked follow-up with police, interviews with other residents who may have witnessed or had knowledge of the events, and timely physical and psychosocial assessments of the involved residents. Similar investigative gaps were identified in an incident where a resident with an above-knee amputation was alleged to have hit another resident. The facility also failed to complete thorough investigations into serious allegations of sexual abuse between residents with significant psychiatric and cognitive diagnoses. In one incident, a CNA reported finding one resident bent over another resident’s bed with his penis in the other resident’s mouth; both residents had diagnoses including paranoid schizophrenia and vascular dementia. Although police were notified and a case number was obtained, the facility did not follow up with law enforcement, did not interview other residents who may have been exposed to or had knowledge of the incident, and did not complete timely physical or psychosocial assessments of either resident. In another case, a cognitively impaired resident reported being touched on the thigh by another resident with severe cognitive impairment while in bed; both residents later denied or could not recall the event, and the facility did not obtain statements from other potentially affected residents or staff who may have been present, determining the allegation unsubstantiated based solely on the residents’ lack of recall. Additional deficiencies in abuse investigations were identified in incidents of resident-to-resident physical abuse and alleged staff-to-resident abuse. In one case, a cognitively intact resident reported that another resident with dementia pinched her breast; while the facility determined that abuse occurred and documented some interviews, it did not obtain statements from other residents potentially affected or staff who may have been present. In another incident, a resident with Alzheimer’s disease and severe cognitive impairment sustained a head laceration when a nurse aide allegedly grabbed the resident by the sweater and shirt, jerked the resident from a seated position, and swung the resident toward the bathroom, causing the resident’s head to hit the doorframe; despite witness statements from another aide and an LPN, the facility ultimately determined it could not verify abuse after the resident later denied being abused. In a separate complaint from a resident with severe cognitive impairment and significant behavioral disturbances, who alleged that an LPN tried to force a pill down his throat and hit him with a TV remote, the facility’s investigation included multiple documents and interviews but did not include interviews of other residents cared for by the implicated LPN. The pattern of incomplete investigations extended to additional resident-to-resident physical abuse incidents. In one event, a resident with vascular dementia and a history of breast cancer attempted to hit a nurse and then slapped another resident with dementia and diabetes in the face; the facility notified responsible parties and updated care plans but did not document interviews with other residents in the area or psychosocial assessments of the involved residents, despite notifying police and receiving a case number. Across these events, the Manager of Quality/Risk Manager, who conducted most of the abuse investigations, confirmed that investigation information was never obtained from the local police department, that timely physical and psychosocial assessments were not completed, and that residents who may have been present or had knowledge of the incidents were not interviewed. The Administrator, who served as the Abuse Coordinator and reviewed investigations, acknowledged that the referenced investigations were not complete, even though facility policy required identifying and interviewing all involved persons and others who might have knowledge of the allegations, and providing complete and thorough documentation of the investigation.
Failure to Implement Abuse Policies and Investigate Multiple Abuse Allegations
Penalty
Summary
Facility administration failed to implement its abuse policies and procedures for 15 of 25 sampled residents, resulting in noncompliance that surveyors determined had caused or had the likelihood to cause serious injury, harm, impairment, or death. The Administrator did not ensure residents remained free from neglect and abuse after multiple allegations of physical, sexual, and other forms of abuse were made by and between residents and staff. Specific incidents included a resident alleging that a staff member grabbed him by the shirt and threw him against a doorframe, causing a laceration above his eye, and several residents reporting that other residents touched them inappropriately in their private areas or engaged in sexual abuse. Another incident involved a resident slapping another resident in the face without provocation. In each of these situations, the administration failed to ensure adequate actions were taken to prevent further potential abuse by staff or residents. The Administrator also failed to ensure thorough investigations of abuse allegations for 14 residents reviewed for abuse. Despite multiple reports and observations of alleged abuse, including sexual abuse between residents, physical abuse by staff toward a resident, and physical abuse between residents, the facility did not conduct comprehensive investigations as required. During an interview, the Administrator and DON confirmed that the facility lacked policies and procedures directing staff on how to identify, report, investigate, and prevent resident abuse, despite the Administrator’s job description assigning responsibility for assuring that care promotes quality, safety, and respect. Surveyors identified Immediate Jeopardy beginning when one resident alleged that another resident sexually abused her by touching her between her legs, and found that the facility’s failure to implement its Abuse Policy placed all residents at risk of unreported and uninvestigated abuse.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency in the facility’s management of psychotropic medications related to informed consent and documentation of risks and benefits for three residents. For one resident with dementia with behavioral disturbances and adjustment disorder, the EMR showed an order for Depakote ER 250 mg at bedtime for mood stabilization and episodic agitation, but there was no signed consent or documentation of risks versus benefits for psychoactive medications in the resident’s miscellaneous documents. Another resident with schizoaffective disorder, bipolar type, bipolar disorder, adjustment disorder with mixed anxiety and depression, and psychosis had intact cognition and was receiving multiple psychoactive medications, including Klonopin, Abilify, Sertraline, and Quetiapine. The consent form for psychoactive medication for this resident was signed and witnessed by facility social workers because the resident had no hands or arms and verbally gave permission, but the form did not list any of the required medication details such as drug name, dosage, frequency, targeted behavior, or potential side effects for any of the four medications. A third resident with dementia with behavioral disturbances, personality disorder, major depressive disorder, and psychosis, and who was severely cognitively impaired with a BIMS score of 0, had a physician order for Valproate Sodium oral solution 250 mg/5 ml, 2.5 ml twice daily for behaviors. Review of this resident’s miscellaneous documents also showed no signed consent or documentation of risks versus benefits for psychoactive medications. During an interview, the DON confirmed she was unable to locate signed psychoactive medication consents for these three residents. The facility’s own policy on the use of psychotropic medications, revised in May 2025, requires that prior to initiating or increasing psychotropic medications, the resident, family, and/or representative be informed of benefits, risks, alternatives, and any black box warnings, and that this information be documented in a format such as a written consent form or narrative note, which was not done in these cases.
Failure to Provide Social Services Assistance for Resident Identification Documents
Penalty
Summary
The facility failed to provide medically-related social services to assist a cognitively intact resident in obtaining a Social Security card and state identification, as required by facility policy. The resident, who had quadriplegia and idiopathic hypotension, was admitted to the facility and had a BIMS score of 15/15, indicating intact cognition. Care planning notes documented that during an interdisciplinary care plan meeting with the resident’s mother/representative, the SW informed her that another attempt had been made to complete the Social Security form so the resident could receive a Social Security card, with the resident’s stated end goal being to obtain a Georgia ID. At a subsequent care plan meeting, the SW discussed with the mother whether she could assist with getting the Social Security card after two unsuccessful attempts, and it was noted there were no psychosocial concerns at that time. An application for a Social Security card was completed for the resident on 11/10/2025, but a review of the comprehensive record showed no documentation of any follow-up by the facility after that date regarding the Social Security card or Georgia ID. In an interview, the resident confirmed he had never received his Social Security card or Georgia ID and stated he would like to obtain those items. The resident’s mother/representative confirmed the card had never been received, reported that the situation had been very stressful for both of them, and stated she lived out of state with her own health problems and was relying on facility staff for assistance. During interviews, the SW and SSD confirmed there had been no follow-up by the facility since 11/10/2025, a period of more than three and a half months, and acknowledged that social services staff were responsible for assisting with such matters. The facility’s Social Services Policy stated that the facility would provide medically-related social services to assist each resident in attaining or maintaining their highest practicable well-being, including making arrangements for obtaining personal items and making referrals to outside entities.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure a safe and abuse-free environment for all individuals in their care.
Failure to Protect Residents' Belongings or Money
Penalty
Summary
A deficiency was identified regarding the protection of residents from the wrongful use of their belongings or money. The report documents that the facility failed to ensure that each resident was safeguarded against unauthorized or improper use of their personal property or financial resources. Specific details about the actions or inactions that led to this deficiency, as well as information about the residents involved or their medical history, are not provided in the report excerpt.
Failure to Ensure Accurate Resident Assessment
Penalty
Summary
A deficiency was identified regarding the facility's failure to ensure that each resident received an accurate assessment. The report notes that the required assessment process was not properly completed for one or more residents, resulting in inaccurate or incomplete information being documented about their condition or needs. This lapse in the assessment process was observed by surveyors during their review of resident records and facility practices.
Neglect Due to Inadequate Supervision in LTC Facility
Penalty
Summary
The facility failed to protect the rights of four residents from neglect, as they did not receive the required one-to-one supervision and monitoring as outlined in their care plans. This deficiency was identified through observations, staff interviews, and record reviews. Specifically, one resident was found on the floor and sent to the hospital for evaluation, although they were discharged without injury. The care plans for these residents indicated severe cognitive impairments and required constant supervision, which was not provided during the night shifts. The facility's policy on abuse, neglect, and exploitation mandates increased supervision for residents requiring one-on-one care. However, the review of CNA assignments from April to July 2024 revealed that the necessary supervision was not implemented during night shifts. Interviews with the Assistant Director of Nursing and the Administrator revealed a lack of awareness regarding the failure to follow care plans and physician orders for one-on-one supervision. The night shift CNA was assigned additional residents, which compromised the ability to provide the required supervision. The investigation into the incident revealed that the CNA assigned to the resident requiring one-on-one supervision was unaware of this requirement and was tasked with caring for 14 additional residents. The facility's failure to ensure that staff were informed and compliant with care plan interventions led to the neglect of the residents' needs. The facility's actions, including the suspension and termination of involved staff, were not part of the deficiency but were noted during the investigation.
Latest citations in Georgia
Surveyors found that clean linens and personal clothing were stored and staged in close proximity to the dirty laundry area, with an open door between the clean and soiled sides and all washer and dryer doors open. Clean resident clothes, unlabeled garments, and bagged items were placed next to dryers and directly in front of the dirty linen room, and dirty barrels had to be pushed past racks of clean clothing to reach the washers, contrary to facility policies requiring separation of clean and soiled linens. Environmental staff believed keeping doors open and covering dirty barrels reduced infection spread, while the Environmental Services Director, IP nurse, and Administrator acknowledged that the dirty room door should be closed, linens should not be on dirty barrels, and clean resident clothing should not be stored in that location.
A resident with a suprapubic catheter, colostomy, sacral wound, and dependence on staff for bathing and hygiene was care planned for Enhanced Barrier Precautions (EBP), including use of PPE during high-contact care. During observed catheter care and a bed bath, a CNA wore only gloves and did not don a gown, despite EBP signage and a star posted on the door and PPE supplies available outside the room. In interviews, the CNA admitted forgetting to wear a gown and not recognizing additional required actions, while the IP nurse and DON confirmed that staff had been educated that gowns and gloves are required for high-contact care involving indwelling devices and wounds under the facility’s EBP policy.
A resident with multiple neurologic and psychiatric diagnoses, intact cognition, and unilateral functional limitations was found with an open box of lubricant eye drops stored at the bedside without any documented assessment for self-administration or prescriber’s order for self-administration or bedside storage, contrary to facility policy. Observations on multiple days confirmed the eye drops remained at the bedside, while staff interviews showed that CNAs and the IP recognized that residents were generally not to self-administer medications and that bedside medications required assessment and orders. The Administrator confirmed that the resident should not have had eye drops in the room and that residents with bedside medications are typically assessed for self-administration, and staff acknowledged that unsecured eye drops at the bedside could be accessed or ingested by other residents and cause harm.
The facility failed to maintain a safe, clean environment when multiple ceiling tiles throughout the building, including above a resident’s bed, near the nurses’ station, in a glass day room above a resident’s chair, and in a main hall, were observed with brown circular stains, bulging, and a white moldy substance. The Maintenance Director confirmed the stained and bulging tiles, acknowledged the risk that tiles above a resident’s bed could fall, and attributed the condition to rain-related roof leaks. The Administrator also confirmed that roof leaks and recent rainfall caused the brownish stains despite her reported daily rounds.
A resident with severe cognitive impairment, on hospice and fully dependent for ADLs, was sexually abused when another cognitively impaired male resident with a long-standing history of sexually inappropriate behavior toward female residents entered her room and placed his hand inside her pants. The abusing resident had multiple dementia and psychiatric diagnoses, was care planned for sexually inappropriate behaviors with prior documented incidents, and was on psychotropic medication for OCD-related sexual obsession. Despite these known risks and existing care plan interventions, he was able to access the female resident’s room and make inappropriate physical contact, and the facility’s investigation substantiated the abuse.
Surveyors found that the facility failed to develop and implement complete, person-centered care plans for two residents. One resident was receiving an antipsychotic (Haloperidol) for schizophrenia with associated behavior and side-effect monitoring orders, but there was no corresponding care plan addressing antipsychotic use or its indication. Another resident had an indwelling Foley catheter for neurogenic bladder related to prostate cancer, with goals to prevent catheter-related trauma; however, the care plan omitted key interventions such as balloon volume parameters and use of a leg strap or securement device, despite physician orders requiring a leg strap and observations showing the catheter positioned under the leg without securement. An MDS coordinator and the administrator acknowledged that required interventions and standard catheter care components were missing from the care plans.
A resident with a history of resistiveness to care and noncompliance with the non‑smoking policy had a comprehensive care plan that was not updated to reflect multiple interventions implemented in response to repeated smoking and vaping violations. Although the care plan noted the need for supervision while smoking and review of the smoking policy, it did not include measures such as daily room searches for smoking materials, added smoke detection in the room, relocation closer to the nurses’ station, q2h visual rounds for smoke, post‑outing nursing checks, initiation of a PAR process for vaping, or issuance of a discharge notice. Facility forms showed inconsistent documentation of daily room searches and incomplete IDT documentation on the PAR tracking, despite multiple documented episodes of policy violations and removal of vaping devices.
A cognitively intact but physically impaired resident with a history of noncompliance with the facility’s non‑smoking policy repeatedly smoked and vaped in his room while keeping multiple vape devices and other items at bedside. The facility’s Smoking Policy required that non‑compliant smokers have daily documented searches and be prohibited from keeping smoking materials in their rooms, yet monitoring forms showed many days without documented searches, Patient at Risk tracking was incomplete, and staff acknowledged that daily room checks and frequent rounds were not consistently performed. Multiple staff, including a CNA, social worker, Infection Preventionist, MDS coordinator, Activities Director, and the Administrator, reported ongoing violations and repeated discovery of vape devices in the resident’s room, including during surveyor observations, demonstrating that the environment was not maintained free from accident hazards and that required supervision and monitoring were not reliably implemented.
Surveyors found that a treatment cart containing topical medications was left unlocked and unattended in a hall across from a resident’s room after wound care was completed by an LPN. The facility’s policy requires that medication carts and supplies be locked or attended and accessible only to licensed or otherwise authorized staff. During interviews, the LPN confirmed the cart had been left unlocked and unattended, the IP LPN confirmed the LPN’s report that the cart was left unlocked, and the Administrator stated that all medications, including topical medications, were expected to be locked when not in sight of authorized staff.
The facility failed to implement its infection prevention and control program by not operationalizing a documented Legionella water management plan despite having a written policy, and by not fully implementing Enhanced Barrier Precautions (EBP) for residents with indwelling devices and other risks. A resident with an indwelling urinary catheter had no EBP care plan or orders, no EBP signage, and staff providing catheter care wore only gloves without gowns, while multiple staff members reported not knowing what EBP was or misidentified who should be on EBP. Another resident receiving tube feeding had care initiated by an LPN who wore gloves but no gown and repeatedly touched her hair with the same gloved hands before handling the feeding tube and equipment, later acknowledging she should have changed gloves and was unaware of EBP requirements, even though other clinical staff stated gowns and gloves should be used for feeding tube care. A resident on isolation for C. diff had a door sign indicating isolation but no instructions for visitors on required PPE or to seek staff guidance, and the IP confirmed there was no system to direct visitors about precautions, contributing to the overall infection control deficiency.
Failure to Maintain Separation of Clean and Soiled Laundry
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to separation of clean and soiled linens. Facility policies titled “Infection Prevention and Control Program” and “Handling Soiled Linens” required that clean linen always be separated from soiled linen. During an observation of the laundry area, all washer and dryer doors were open in the clean linen area. Clean linens, including sheets, towels, blankets, and washcloths, were folded on a table to the left of the washer and dryer room. On the right side of the room, next to the dryers and directly in front of the open door to the dirty laundry room, there were residents’ clean clothes on a rack, piles of folded clean clothes to be hung, a rack of unlabeled clothes, and a bag of unlabeled clothes. Dirty laundry barrels had to be pushed past the clean clothing on the racks to reach the washers, placing soiled items in close proximity to clean items despite policy requirements for separation. Environmental staff working in the laundry stated they believed they were reducing the spread of infection by keeping all doors open, covering dirty barrels, and circulating air, and they explained that the uncovered rack and bagged clothes near the dirty area were no-name clothes sometimes distributed to residents in need. They also stated that the rack of clean personal resident clothing parked in front of the open dirty linen room door was awaiting distribution by a staff member who worked only at night. The Environmental Services Director reported that the door to the dirty side of the laundry should always be closed and that no linen should be on top of dirty barrels. The Infection Preventionist nurse, when shown pictures and concerns about cross-contamination, confirmed there was a problem in the laundry but stated she had not been aware of it previously. The Administrator stated that residents’ clothes should not be stored where they were observed and should be handed out immediately once clean, and that she expected the laundry to be organized to prevent cross-contamination between dirty and clean clothes.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff followed its Enhanced Barrier Precautions (EBP) policy for the use of personal protective equipment (PPE) during high-contact care. The facility’s EBP policy, updated February 2025, requires gowns and gloves for residents with wounds and/or indwelling medical devices, including urinary catheters and ostomies, when staff perform high-contact activities such as bathing, dressing, toileting, hygiene, and catheter care. The policy also directs that gowns and gloves be made available near or outside the resident’s room and that EBP be implemented for residents with indwelling devices or wounds, even if they are not known to be infected or colonized with a multidrug-resistant organism. The resident involved had a suprapubic catheter, colostomy, sacral wound, and neurogenic bladder and bowel, and was care planned for EBP implementation during catheter and skin care. The resident was cognitively intact but dependent on staff for bathing, dressing, toileting, hygiene, bed mobility, and transfers, and used an indwelling catheter and ostomy. During an observation, a CNA provided suprapubic catheter care and a bed bath to this resident while only wearing gloves, despite EBP signage and a star posted on the door and PPE supplies available outside the room. The CNA did not don a gown and was unable to identify any additional actions needed before care until prompted about the EBP signage, at which point he acknowledged he should have worn a gown but forgot. In a subsequent interview, the IP nurse and DON confirmed that staff had been educated that gowns are required during high-contact care for residents with catheters, colostomies, and other devices, and that the posted signage and star were intended to alert staff to the need for enhanced PPE use.
Failure to Assess and Obtain Orders for Self-Administration and Bedside Medication Storage
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policies for self-administration of medications and bedside medication storage for one resident. The facility’s policies require that residents who wish to self-administer medications must be assessed by the interdisciplinary team for cognitive, physical, and visual ability, and that a prescriber’s order for self-administration and bedside storage must be present in the medical record and reflected on the MAR and medication label. For the resident in question, who had diagnoses including cerebral infarction, major depressive disorder with psychotic symptoms, PTSD, hemiplegia and hemiparesis, speech and language deficits, and cerebral atherosclerosis, the EHR showed no assessment for self-administration and no physician order for self-administration or bedside storage, despite active ophthalmic medication orders. The resident’s MDS documented intact cognition with a BIMS score of 15, use of corrective lenses, and functional limitations in range of motion on one side of both upper and lower extremities. Surveyor observations on two consecutive days found an open box of lubricant eye drops on the resident’s bedside table. Staff interviews revealed inconsistent understanding and enforcement of the facility’s policies. A CNA stated that residents did not self-administer medications and that only nurses administered them, but also reported that when she previously reported the eye drops, she was told the resident could have them because he was independent. The Infection Preventionist acknowledged the resident had an order for eye drops and believed he obtained them from the VA, and stated he should not have the lubricant eye drops because they were a hazard for other people. The Administrator confirmed that typically a resident with medications at the bedside should be assessed for self-administration and stated the resident should not have eye drops in his room. The report notes that unsecured medications at the bedside had the potential to cause adverse reactions if accessed or ingested by other residents.
Failure to Maintain Safe and Clean Ceiling Surfaces Throughout Facility
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable homelike environment as required by its Maintenance Service policy, which assigns the Maintenance Department responsibility for keeping the building in good repair and free from hazards. Surveyors observed multiple stained and damaged ceiling tiles in several areas of the facility, including near the nurses' station, in a resident bedroom (room [ROOM NUMBER]A), in the glass day room, and in the middle of the east hall. On several occasions, ceiling tiles near the nurses' station were noted to have tannish-brown circular stains of varying sizes, and at one point a white, moldy substance was observed on a ceiling tile in that same area. In room [ROOM NUMBER]A, surveyors observed brown rings roughly 16 inches in diameter on ceiling tiles located directly above a resident’s bed, with the Maintenance Director later confirming that these tiles were stained, bulging, and at risk of falling on the resident. Additional observations in the glass day room identified two stained ceiling tiles above a resident’s chair, each with brown circular stains approximately three inches in diameter. In the east hall, a ceiling tile with a brown circular stain approximately 10 inches in diameter was also documented. The Maintenance Director and the Administrator both acknowledged that the stains and damage were related to roof leaks associated with recent rainfall, and the Administrator confirmed awareness of roof leaks that had previously been repaired and that the brownish stains were due to recent rain.
Failure to Prevent Sexual Abuse of a Cognitively Impaired Resident by Another Resident
Penalty
Summary
The facility failed to protect a dependent, cognitively impaired resident (R113) from sexual abuse by another resident (R12). R113 had severe cognitive impairment with a BIMS score of 5, was on hospice care, and was fully dependent for toileting, bathing, dressing, footwear, and personal hygiene. On the day of the incident, a CNA observed R12 in R113’s room with his right hand inside R113’s pants while she was seated in a geriatric chair. Staff witness statements and nursing progress notes documented that R12 was found in R113’s room with his hand in her pants, and the facility’s investigation substantiated that R12 touched R113 inappropriately. R12 also had severe cognitive impairment with a BIMS score of 4 and multiple psychiatric and dementia-related diagnoses, including vascular dementia with mood disturbance, Alzheimer’s disease, major depressive disorder, obsessive-compulsive personality disorder, unspecified psychosis, and unspecified mood affective disorder. He required extensive physical assistance, used a manual wheelchair, and was fully dependent for toileting, bathing, lower body dressing, and footwear. R12’s care plan, in place since 2017, identified him as having sexually verbally and physically inappropriate behavior, including documented prior incidents in which he inappropriately touched or attempted to touch female residents. His care plan included interventions such as discussing his behavior when reasonable, explaining that it was inappropriate, intervening to protect others, diverting his attention, and removing him from situations as needed, as well as monitoring and recording occurrences of target behaviors such as sexual aggression toward others. Despite this known history of sexually inappropriate behavior toward female residents and the presence of care plan interventions, R12 was able to enter R113’s room and place his hand inside her pants. The Administrator confirmed that the CNA reported finding R12 in R113’s room with his hand in her pants while R113 was in her wheelchair, and that the facility’s investigation substantiated the abuse allegation. The facility’s abuse policy stated that it would not condone resident abuse by anyone, including other residents, and defined sexual abuse to include sexual harassment, sexual coercion, or sexual assault. The occurrence of this incident demonstrated that the facility did not effectively prevent sexual abuse of R113 by another resident, despite R12’s documented behavioral history and existing care plan.
Failure to Develop and Implement Complete Care Plans for Antipsychotic Use and Foley Catheter Management
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for identified resident needs, as required by its Comprehensive Care Plan policy. The policy states that care plans must address all needs identified in the comprehensive assessment, including medical, nursing, mental, and psychosocial needs, and must be developed within seven days after completion of the comprehensive MDS assessment. It also requires that all triggered Care Area Assessments (CAAs) and other factors identified by the IDT or resident preferences be incorporated into the plan of care. For one resident, R44, the clinical record showed physician orders for Haloperidol 10 mg by mouth twice daily for schizophrenia, along with orders for behavior monitoring and psychiatric medication side effect monitoring. Despite these orders, the resident’s care plan dated 03/11/2026 did not include any care plan addressing antipsychotic medication use or its indication. The MDS Coordinator stated that all residents receiving antipsychotic treatment should have a comprehensive care plan in place beginning with the date the medication was originally ordered, and upon review of the record confirmed that such a care plan was not present for this resident at the time of the survey. For another resident, R3, the care plan dated 03/13/2026 identified a problem of an indwelling catheter secondary to neurogenic bladder related to prostate cancer, with goals including remaining free from catheter-related trauma. The listed interventions included positioning the catheter bag and tubing below bladder level, monitoring and documenting intake and output per policy, and monitoring for pain, discomfort, and signs and symptoms of UTI. However, the care plan did not address the amount of water in the catheter balloon, use of a leg strap or securement device, or other securement measures. Physician orders specified checking a leg strap every shift and documented that the resident was admitted with an 18F catheter attached to a bedside drainage bag, but observations showed the Foley catheter positioned under the resident’s leg without a leg strap or securement device on two occasions, and a CNA reported being unaware that a leg strap was required. The MDS Coordinator confirmed that these ordered interventions were missing from the care plan.
Failure to Revise Care Plan for Ongoing Smoking Policy Noncompliance
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive care plan to reflect current interventions implemented in response to ongoing noncompliance with the facility’s non‑smoking policy. The facility’s policy requires that the comprehensive care plan be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment, and that it include measurable objectives, timeframes, and alternative interventions as needed, with qualified staff notified when changes are made. The resident’s care plan included a focus on resistiveness to care and noncompliance with smoking, noting that the resident continued to go outside beyond facility property to smoke, and an intervention to review the smoking policy with the resident. Another care plan focus identified the resident as a smoker requiring supervision while smoking, with interventions stating the resident required supervision while smoking and that the charge nurse should be notified if a smoking policy violation was suspected. Despite repeated and ongoing noncompliance with the non‑smoking policy, the care plan was not revised to include additional interventions that were actually implemented. These unreflected interventions included daily room searches for smoking paraphernalia, placement of a smoke detector in the resident’s room, relocation of the resident’s room closer to the nursing station, every‑two‑hour visual rounds to check for smoke, nursing checks upon return from outings, initiation of a Patient at Risk (PAR) process for vaping noncompliance, and issuance of a 30‑day discharge notice for repeated violations of the non‑smoking policy. Documentation on the Smoking Materials Monitoring Form showed initials on selected days only, indicating daily room searches were not consistently completed and documented for the entire month. The PAR Smoking Tracking form documented multiple observations of vaping in the room, repeated room checks, removal of vapor devices, and the resident’s refusal to comply with facility policies, with later weeks lacking IDT signatures and documentation, while the PAR Grid showed multiple prior entries for violating the non‑smoking policy.
Failure to Control Smoking and Vaping Hazards for a Noncompliant Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision for a resident with a known history of noncompliance with the facility’s non‑smoking policy. The facility’s Smoking Policy requires that residents not be allowed to keep cigarettes, cigars, pipes, matches, or lighters in their possession or rooms, and that non‑compliant smokers receive daily searches with documentation, while compliant smokers receive weekly searches. The policy also requires incident reports and review in a “Patients at Risk” process whenever smoking materials are found. Despite these written procedures, the resident’s Smoking Materials Monitoring Form for April showed multiple days without documented searches, indicating that required daily room searches were not consistently completed or recorded. The resident at issue was cognitively intact, with a BIMS score of 15, and had significant physical impairments including hemiplegia and hemiparesis on the left side, use of a manual wheelchair, and other neurologic and psychiatric diagnoses such as cerebral aneurysm, cerebral infarction, major depressive disorder with psychotic symptoms, PTSD, and speech and language deficits. The care plan identified the resident as resistive to care and noncompliant with smoking, noting that he continued to go outside beyond facility property to smoke, and also identified him as a smoker requiring supervision while smoking. Progress notes and Patient at Risk documentation showed a pattern of repeated violations of the non‑smoking policy, including multiple instances of vaping and smoking in his room, with staff repeatedly finding vape devices and other smoking paraphernalia in his possession and in his room. Throughout the period reviewed, staff observations and interviews confirmed ongoing noncompliance with the smoking policy and inconsistent implementation of the facility’s own interventions. Staff documented several occasions when the resident was observed vaping or smoking in his room, including in the presence of a state surveyor, and room searches revealed multiple vape devices hidden under the sheets. Staff interviews indicated that daily room checks were not always performed due to competing demands, that logs of every‑two‑hour rounds were not maintained, and that there was confusion or inconsistency regarding whether the resident could keep items such as air freshener at bedside. The social worker, Infection Preventionist, MDS coordinator, Activities Director, CNA, and Administrator all acknowledged that the resident’s room had to be searched for cigarettes and vaping paraphernalia and that prohibited items were repeatedly found, while documentation showed gaps in the required daily searches and incomplete follow‑through on the Patient at Risk tracking process. These actions and inactions resulted in the environment not being kept free from accident hazards as required by the facility’s policy and regulatory standards. The deficiency is further supported by the facility’s own records showing repeated entries on the Patient at Risk grid for violations of the non‑smoking policy over an extended period, as well as narrative notes describing the resident’s statements that he would continue to vape in his room and would simply obtain new devices if they were confiscated. Despite the known pattern of behavior and the facility’s policy requiring close supervision, daily searches, and thorough documentation for non‑compliant smokers, the monitoring forms and staff interviews demonstrate that these measures were not consistently carried out. The presence of multiple vape devices and cans of air freshener at the bedside during surveyor observations, along with staff acknowledgment that room checks were missed and that logs of frequent rounds were not kept, illustrate the facility’s failure to effectively implement its own safety procedures to prevent accident hazards related to smoking and vaping in the resident’s room.
Unlocked and Unattended Treatment Cart with Topical Medications
Penalty
Summary
Surveyors identified a deficiency related to medication storage when a treatment cart containing topical medications was left unlocked and unattended in a hall. The facility’s policy titled “Medication Storage in the Facility,” effective 10/01/2025, states that the medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff lawfully authorized to administer medications, and that medication rooms, carts, and supplies are to be locked or attended by authorized personnel. During an observation on 04/29/2026 at 9:35 AM, after wound care was provided to resident R3 by the wound care LPN, the treatment cart was observed left in the [NAME] hall across from R3’s room, unlocked and unattended for 30 minutes. In an interview, the wound care LPN confirmed that the treatment cart had been left unlocked and unattended. The Infection Preventionist LPN later confirmed that the wound care nurse told her the cart was left unlocked, and the Administrator stated that her expectation was that all medications, including topical medications, be locked when not in sight of a licensed nurse or authorized person. This deficient practice occurred in a facility with a census of 94 residents and involved the failure to follow the facility’s own policy requiring that medication carts be locked or attended by authorized personnel, resulting in unsecured access to topical medications on the treatment cart.
Failure to Implement Legionella Water Management and Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to provide and implement an infection prevention and control program, including a documented water management plan for Legionella and other waterborne pathogens, and a fully implemented Enhanced Barrier Precautions (EBP) program. The Administrator stated there was no Legionella water program in place, and the Maintenance Supervisor reported he was unaware of the requirement for such a program. This was despite the existence of a written Legionella Water Management Program policy, revised in September 2022, which described the need for an interdisciplinary water management team, detailed water system diagrams, identification of risk areas and situations for Legionella growth, control measures, monitoring systems, and annual review. Interviews confirmed that the expectation was that the facility would be conducting this water program, but it was not being done. The facility also failed to implement EBP for residents with indwelling medical devices and other risk factors, as required by its own policy. One resident with Alzheimer’s disease, urinary obstruction, and emphysema had an indwelling urinary catheter documented in the care plan and physician orders, but the care plan did not address EBP related to the catheter, and there was no order for EBP in the record. During catheter-related care, a CNA wore gloves but did not wear a gown, and there was no EBP signage or PPE setup at the room. Multiple staff members, including CNAs and a housekeeper who regularly worked on the resident’s hallway, reported they did not know what EBP was or incorrectly associated EBP only with residents on Transmission-Based Precautions. The DON acknowledged that an attempt to roll out EBP months earlier had not been completed, and that expected signage and PPE caddies for EBP were not fully in place. Additional infection control lapses were observed during tube feeding care and contact isolation. A resident receiving continuous tube feeding had a care plan and physician’s order for enteral nutrition, and an LPN initiated the feeding while wearing gloves but no gown. During the procedure, the LPN repeatedly touched her hair with the same gloved hands and then handled the feeding tube, pump, and syringe used to inject air and check residuals, only removing gloves and using hand sanitizer at the end. The LPN later acknowledged she should have changed gloves after touching her hair and stated she did not know what EBP was or that a gown was required for feeding tube care, while another LPN and the IP stated that EBP with gown and gloves should be used for feeding tube care and that staff should not touch their hair during care without changing gloves and performing hand hygiene. For a resident with a positive urine culture and a subsequent positive C. difficile culture who was on isolation, the door sign indicated isolation but did not provide instructions for visitors on required precautions or direct them to staff for guidance. The IP confirmed there was no system to direct visitors about PPE use for residents on contact isolation and acknowledged that visitors would not know to wear PPE if it was simply present in or on the door of the room. Overall, the survey findings show that the facility did not operationalize its written Legionella water management policy and did not consistently apply its EBP policy for residents with indwelling devices or wounds. Staff interviews and observations demonstrated a lack of knowledge and implementation of EBP, incomplete use of PPE during high-contact care activities such as catheter care and tube feeding, and unclear isolation signage that did not instruct visitors on appropriate precautions. These combined inactions and omissions in policy implementation, staff education, and practice led to the cited infection prevention and control deficiency.
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