Crossroads Of Flowery Branch Of Journey Llc, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Flowery Branch, Georgia.
- Location
- 4595 Cantrell Road, Flowery Branch, Georgia 30542
- CMS Provider Number
- 115327
- Inspections on file
- 21
- Latest survey
- January 16, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Crossroads Of Flowery Branch Of Journey Llc, The during CMS and state inspections, most recent first.
Two residents with significant medical conditions, including dementia and heart failure, made allegations of staff-to-resident abuse that were reported to facility staff but not reported to administration or the State Survey Agency within the required timeframe. Facility staff, including the DON and SSD, failed to document, report, or investigate these allegations as required by policy, resulting in a lack of appropriate response to the reported incidents.
The facility did not properly identify or investigate allegations of staff-to-resident abuse for two residents. In one case, a resident with dementia and on hospice care reported being hurt by staff, but no investigation was conducted. In another case, a cognitively intact resident was found with bruising, but the investigation lacked interviews with the resident and other residents, and there was no analysis of the cause or staff training on abuse reporting.
Two residents experienced significant weight loss that was not accurately coded in their MDS assessments. One resident with dysphagia lost over 8% of body weight, and another with Parkinson's disease lost over 13% in a month, but these losses were not documented in the MDS. Staff interviews confirmed the omissions, and the DON acknowledged the expectation for accurate MDS coding.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the care plan was not prepared, reviewed, and revised by a team of health professionals as required.
A deficiency was cited when a resident was not provided with sufficient food and fluids to maintain their health, as required. The report does not include further details about the circumstances or the resident's condition.
The facility failed to ensure that two CNAs completed the required in-service training hours, with CNA AA completing only 5.5 out of 6 hours and CNA FF completing 1.15 out of 12 hours. This deficiency was identified during a staff development review. Interviews revealed a lack of awareness and oversight, with management collectively responsible for overseeing in-services but no designated person for the task. The ADON and CNA AA were unaware of the non-compliance, while the DON expected all CNAs to complete their in-service hours to ensure resident safety.
The facility failed to document and communicate resolutions to resident concerns voiced during Resident Council meetings. Despite the policy requiring follow-up, the Activity Director and DON acknowledged that resolutions were not documented, leaving residents unaware of outcomes or grievance procedures.
The facility failed to maintain a safe and homelike environment, with six resident rooms having furniture in disrepair and leaking PTACs. Dressers in several rooms were missing drawers or knobs, and PTACs in other rooms leaked water onto the floors. The Maintenance Director confirmed these issues, citing extreme heat and condensation as causes for the PTAC leaks, and noted challenges in addressing these problems due to working alone.
CNAs in the facility failed to use hand sanitizer between distributing lunch trays to residents, despite being reminded by an RN. The CNAs admitted to forgetting the practice and had not received handwashing training since starting at the facility. The DON confirmed the expectation for proper hand hygiene to prevent infection control issues.
A resident with multiple chronic conditions experienced a significant change in condition, including altered mental status and respiratory distress, leading to transfer to the ED. Despite assessments and actions taken by nursing staff and a nurse practitioner, there was no timely documentation of the change of condition or the events leading to the transfer in the medical record, nurses' notes, 24-hour report, or SBAR report. The deficiency was only identified after surveyor inquiry, prompting late entries.
Failure to Timely Report and Investigate Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of staff-to-resident abuse to facility administration and/or to the State Survey Agency (SSA) within the required two-hour timeframe for two residents. For the first resident, who had diagnoses including dementia, anxiety, malnutrition, and muscle weakness and was on hospice care, allegations of being hurt by staff resulting in bruising and wounds were reported to the Social Service Worker (SSW) on two occasions. The SSW reported these allegations to the Administrator and Social Service Director (SSD), but there was no evidence that the facility reported or investigated the incidents as required. The Director of Nursing (DON) and SSD acknowledged awareness of the allegations but did not report or document them, with the DON attributing one bruise to a prior fall and the Administrator expressing personal doubts about the validity of the reports, which led to no investigation or reporting. For the second resident, who had heart failure, kidney failure, depression, hypertension, muscle weakness, and was also on hospice care, complaints of rough treatment by staff were made to both the resident's family and facility staff. A Certified Nurse Aide (CNA) reported to the SSD that the resident alleged a staff member had held her hand too hard and caused pain. The SSD documented the allegation in a daily planner but did not report or investigate the incident, and could not recall the reporting CNA. The Administrator later confirmed a lack of awareness and concern that these issues were not reported or investigated as required. These failures were in direct violation of the facility's policy, which mandates immediate reporting of all alleged violations.
Failure to Investigate Allegations of Staff-to-Resident Abuse
Penalty
Summary
The facility failed to identify and/or investigate allegations of staff-to-resident abuse for two residents. For the first resident, who had diagnoses including dementia, anxiety, malnutrition, and muscle weakness and was on hospice care, there were two separate reports made by a hospice social worker that the resident claimed to have been hurt by staff, resulting in bruising and wounds. These reports were communicated to both the facility Administrator and Social Service Director, but there was no evidence that any investigation was initiated or documented by the facility. The Director of Nursing confirmed that no investigation was conducted, and the Administrator could not locate any report of the allegations, acknowledging that they should have been investigated. For the second resident, who was cognitively intact and had multiple medical conditions, a family friend reported bruising, which was subsequently reported to the Administrator. While an incident report was created and some staff interviews were conducted, there was no documentation that the resident was interviewed, that other residents were questioned, or that the cause of the bruising was analyzed. Additionally, there was no evidence of staff training on reporting or investigating injuries of unknown origin, nor documentation of measures to protect the resident or prevent recurrence. The Administrator admitted to being unaware that the investigation was incomplete and agreed that all such allegations should be thoroughly investigated.
Failure to Accurately Code Significant Weight Loss in MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were accurately coded to reflect significant weight loss for two residents. For one resident with dysphagia, weight records showed a loss of 8.73% over a short period, but the quarterly MDS assessment did not document this significant weight loss. The resident's care plan noted a risk for weight loss but did not address the actual significant loss that had occurred. During observation, the resident expressed concerns about being skinny, further indicating awareness of her weight change. For another resident with Parkinson's disease and other brain disorders, weight records indicated a 13.54% loss in one month, but the quarterly MDS assessment failed to code this significant weight loss. Progress notes showed interventions such as appetite stimulation and dietician involvement, and the care plan was revised to note significant weight loss at a later date. Staff interviews confirmed that the MDS assessments for both residents did not reflect the significant weight loss, and the DON acknowledged that the MDS should have included this information.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Failure to Provide Adequate Nutrition and Hydration
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide adequate food and fluids necessary to maintain a resident's health. The report notes that the required provision of nutrition and hydration was not met, which is essential for the resident's well-being. Specific details about the actions or inactions leading to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Deficiency in CNA In-Service Training Hours
Penalty
Summary
The facility failed to ensure that two of its Certified Nursing Assistants (CNAs) completed the minimum required in-service training hours during the review period from February 1, 2023, to January 31, 2024. Specifically, CNA AA, who worked part-time, completed only 5.5 hours out of the required 6 hours, and CNA FF, who worked full-time, completed only 1.15 hours out of the required 12 hours. This deficiency was identified during a staff development review conducted on July 5, 2024, as documented in the Alliant Certified Nursing Assistant (CNA) Annual Report. The facility's policy mandates that each nurse aide must receive at least 12 hours of in-service training annually, based on their employment date. Interviews with facility staff revealed a lack of awareness and oversight regarding the completion of in-service training hours. The Assistant Director of Nursing (ADON) stated that management was collectively responsible for overseeing in-services and education, but there was no designated person for this task. The ADON was unaware of the non-compliance of CNAs AA and FF with their in-service hours. Similarly, CNA AA was not aware of her shortfall in meeting the in-service education requirement, although she believed she had completed the necessary training. The Director of Nursing expressed an expectation that all CNAs should have their in-service hours completed to prevent potential negative outcomes affecting resident safety.
Failure to Document and Communicate Resolutions to Resident Concerns
Penalty
Summary
The facility failed to ensure proper follow-up and communication regarding resident concerns and recommendations voiced during Resident Council meetings. The review of the facility's policy on Resident Council Meetings indicated that the Activity Director was responsible for facilitating meetings and responding to written requests from the group. However, the facility did not document responses to concerns or recommendations, nor did they provide evidence of thorough investigation or resolution of these issues. This lack of documentation and follow-up was evident in the review of nine Resident Council meeting minutes, which were incomplete and lacked evidence of resolution or satisfaction from the residents. During a Resident Council Meeting, several residents expressed that they had voiced concerns and recommendations but had not received any follow-up or resolutions. Additionally, these residents were unaware of how to file a grievance or who the grievance official was. Interviews with the Activity Director and the Director of Nursing revealed that while concerns were verbally communicated to residents, there was no documentation of resolutions. The Director of Nursing acknowledged the need for documentation and expressed that staff were expected to document resolutions to residents' concerns.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by the disrepair of furniture and packaged terminal air conditioners (PTACs) in six out of 56 resident rooms. Specifically, rooms A6-2, B10-1, and C18-2 had dressers with missing drawers and/or knobs, while rooms C13, C15, C18, and C19 had PTACs that leaked water onto the floors. These deficiencies were identified through observations, resident and staff interviews, and a review of the facility's maintenance policy. The policy required routine inspections and immediate correction of any issues, which were not adhered to in this case. During an interview, the Maintenance Director confirmed the observations and acknowledged that the PTACs had been leaking intermittently over the past month due to extreme heat causing increased condensation. Despite the units still functioning, they were not effectively directing the fluid outside, leading to water accumulation on the floors. The Maintenance Director, who worked alone, stated that he cleaned the affected floors every two to three days but had no immediate plans to replace the PTACs. He also mentioned difficulties in conducting routine rounds due to his workload, which contributed to the ongoing issues with the facility's environment.
Failure to Maintain Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to maintain proper hand hygiene practices, which are crucial for preventing infections and cross-contamination. During an observation on Hall A, Certified Nursing Assistants (CNAs) were seen distributing lunch trays to residents without using hand sanitizer between each delivery. Despite being reminded by a Registered Nurse (RN) to use hand sanitizer, the CNAs continued to neglect this practice. This oversight was observed in multiple rooms, indicating a pattern of non-compliance with the facility's hand hygiene policy. Interviews with the CNAs revealed that they were aware of the requirement to use hand sanitizer but admitted to forgetting to do so. Both CNAs also disclosed that they had not received any handwashing hygiene training since starting their employment at the facility, although they had learned about it during their initial CNA training. The Director of Nursing confirmed that the expectation was for all CNAs to adhere to proper hand hygiene protocols to prevent infection control issues and ensure resident safety.
Failure to Document Change of Condition and Transfer
Penalty
Summary
The facility failed to ensure accurate and timely documentation of a resident's change of condition, as required by its own policy and professional standards. A resident with multiple complex diagnoses, including hypertensive heart and chronic kidney disease, end stage renal disease, dementia, and dependence on dialysis, experienced a significant change in condition characterized by altered mental status, fever, and respiratory distress. The resident was ultimately sent to the emergency department, where diagnoses included hypernatremia, dehydration, acute respiratory failure, sepsis, and pneumonia. Despite these events, there was no documentation in the resident's medical record, nurses' notes, 24-hour report, or SBAR report regarding the change of condition or the events leading to the transfer. Staff interviews confirmed that the nurse and nurse practitioner assessed the resident and arranged for transfer to the hospital, but failed to document the assessment, observations, or rationale for the transfer at the time of the event. The nurse practitioner only wrote an order to send the resident out, without specifying the reason, and the LPN believed she had charted the information but had not. The CNA reported changes in the resident's behavior and communicated this to the nurse, who then took action, but again, no documentation was made at the time. The lack of documentation was only discovered after surveyor inquiry, at which point late entries were made.
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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