Crossview Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pineview, Georgia.
- Location
- 402 E. Bay St, Pineview, Georgia 31071
- CMS Provider Number
- 115541
- Inspections on file
- 19
- Latest survey
- April 21, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Crossview Care Center during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and a large trust account balance had over $4,800 in clothing purchased in their name, documented with a perfectly formed "X" signature witnessed by the former administrator and receptionist, despite the resident’s usual mark being irregular. Staff reported being told not to inform the resident about the substantial funds in the account, and the resident later stated they were unaware of both the purchase and the extent of their funds. The former administrator admitted ordering a large wardrobe as a spend-down from the account, not disclosing the exact balance to the resident, and failing to return incorrectly sized clothing, resulting in misappropriation of the resident’s money without clear, informed consent.
A resident reported an unauthorized online clothing purchase charged to their funds, and the facility documented this as an allegation of exploitation/misappropriation of property. Facility policy required prompt reporting of such allegations to the Abuse Coordinator, state agency, and law enforcement. However, there was no evidence that the Sheriff’s Department was notified, and later contact with an investigator confirmed no report existed. Internal email communication also showed that police had not been to the facility, and staff did not perform a documented follow-up with law enforcement, resulting in a failure to report the alleged misappropriation as required.
The facility failed to provide showers or baths according to the preferences and schedules of three residents, leading to a deficiency in promoting resident self-determination. One resident, with a history of aphasia and hemiplegia, received fewer showers than scheduled despite grievances. Another resident with COPD and diabetes also received showers less frequently than scheduled. A third resident, with cerebral infarction and schizophrenia, reported that showers were not given due to a lack of towels. Staff interviews revealed issues with linen availability, affecting the ability to provide showers as scheduled.
A resident with multiple diagnoses, including Alzheimer's and dementia, was found with a significant bruise around the left eye that was not reported to the State Agency within the required time frame. Staff interviews revealed uncertainty about the cause of the bruise, and the facility administrator confirmed that no report had been made until prompted by a surveyor's inquiry, violating the facility's policy and regulatory requirements.
A resident with multiple diagnoses, including dementia and intellectual disabilities, was found with a bruise on the left eye on two occasions, but the facility failed to investigate or report the injury as required by their abuse prevention policy. Interviews with staff, including an LPN and the administrator, revealed a lack of documentation and clarity regarding the incident, leading to a deficiency in the facility's handling of the situation.
The facility failed to accurately report direct care staffing data to CMS for Q1 2024, resulting in a one-star staffing rating. Discrepancies were found between the actual nursing hours worked on weekends and the hours reported. Current leadership was unable to explain the discrepancies, as they were not in their positions during the period in question.
The facility failed to maintain a clean and sanitary environment in the laundry department, leading to potential cross-contamination of dirty and clean laundry. Observations revealed spider webs, dust buildup, and grime on various surfaces, as well as a leaking handwashing sink. Staff interviews confirmed that daily cleaning was not adequately performed.
The facility failed to ensure that four residents did not have unsecured unauthorized medications stored at their bedside. The residents had various medications and antiseptic products in their rooms without being assessed for self-administration. Staff were unaware of these items, and the Director of Nursing confirmed that none of the residents were care planned or assessed to self-administer medications.
The facility failed to maintain a safe, clean, and homelike environment in the 100 Hall, with issues such as a loose handrail, jagged door frames, rusty heaters, and damaged flooring. Specific rooms and bathrooms had peeling paint, stained tiles, and jagged edges, which were confirmed by the Administrator, Maintenance Director, and Housekeeping Supervisor.
The facility failed to follow the care plan for a resident with COPD, resulting in the resident receiving an incorrect oxygen level. Observations and staff interviews confirmed that the oxygen was set at 4.5 L/M, contrary to the physician's order.
A resident with COPD was observed receiving oxygen at 4.5 L/M instead of the physician-ordered 2 L/M. Staff were unaware of the correct setting, and the resident confirmed she did not alter the oxygen levels. The DON and MDS Coordinator acknowledged the failure to follow the physician's orders, putting the resident at risk.
Misappropriation of Resident Trust Funds for Unauthorized Clothing Purchase
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from misappropriation of resident trust account funds, contrary to its policy on Freedom of Abuse and Abuse Prevention. The policy defined misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident’s belongings or money without consent. The resident involved had mild intellectual disabilities, a brief psychotic disorder, paranoid personality disorder, and seizures, and an MDS BIMS score of 09 indicating moderately impaired cognition. The resident had a transferring resident fund account set up with the facility for automatic transfer of care-cost payments. An invoice dated 11/25/2025 from a vendor showed that 63 articles of clothing, ranging from medium to 3X sizes, were purchased in the resident’s name for a total of $4,899.05. The invoice bore a perfectly formed “X” mark, purported to be the resident’s authorization, witnessed by the previous Administrator and the previous receptionist. However, other facility documents, including a Check Cashing Authorization form and a Resident Shopping List/Spending Report, showed that the resident’s usual “X” mark had very irregular lines. Staff, including an LPN, reported concerns that the resident could not make a perfect “X” and that they had heard the previous Administrator and receptionist instructed staff not to tell the resident he had a substantial amount of money in his account. The resident later reported to the corporate President of Operations that he was unaware of the clothing purchase and did not authorize it, and also that he did not know about the funds in his Resident Funds Management System. In a written statement, the previous Administrator acknowledged ordering a large amount of clothing for the resident because she believed he needed a spend-down from his account and stated she did not tell him the exact amount of money in his account, citing concerns about his decision-making and susceptibility to manipulation by other residents. She also stated she ordered clothing in different sizes after asking if she could get him a new wardrobe, but the resident did not like the outfits and she had accidentally ordered the wrong sizes and had not returned them. These actions and omissions resulted in the use of the resident’s trust account funds for a large clothing purchase without clear, informed authorization from the resident, constituting misappropriation of resident property as defined by facility policy.
Failure to Report Alleged Misappropriation of Resident Funds to Law Enforcement
Penalty
Summary
The facility failed to protect a resident from misappropriation of funds by not ensuring timely and complete reporting of an allegation of exploitation to the state agency and law enforcement, as required by its own abuse prevention policy. The facility’s policy, titled Freedom of Abuse, Abuse Prevention: Fast Alerts, required that any complaint, allegation, observation, or suspicion of abuse, neglect, exploitation, mistreatment, injuries of unknown origin, or misappropriation of resident property be communicated to the Abuse Coordinator and reported immediately, but no later than two hours if involving abuse or serious bodily injury, and within 24 hours if not. An incident report dated 02/06/2026 documented an allegation of exploitation/misappropriation of resident property/funds for one resident, indicating the resident had not authorized an online clothing purchase made on 11/25/2025. Record review of the facility’s investigation showed no evidence that the Sheriff’s Department was notified of this allegation. During an interview, the Interim Administrator reported that when he later contacted an investigator with the Sheriff’s Department, he was told there was no report on file for the 02/06/2026 allegation. An email dated 02/10/2026 from the previous President of Operations asked whether the police had been by and was answered in the negative, with no documentation that staff followed up with the Sheriff’s Department. In a subsequent interview, the Interim Administrator acknowledged that staff should have made a follow-up call to the Sheriff’s Department, confirming that the required law enforcement notification and follow-up did not occur as outlined in the facility’s policy.
Failure to Provide Scheduled Showers/Baths
Penalty
Summary
The facility failed to ensure that three residents received showers or baths according to their preferences and scheduled days, leading to a deficiency in promoting resident self-determination and choice. Resident 1, who had a history of aphasia, dysphagia, and hemiplegia, was scheduled for showers on Mondays, Wednesdays, and Fridays but received fewer showers than scheduled. Despite grievances filed by the resident and their family, the facility did not consistently provide showers as per the resident's preference. Resident 2, diagnosed with COPD, diabetes, and hemiplegia, was scheduled for showers on Tuesdays, Thursdays, and Saturdays. However, the resident received showers less frequently than scheduled, and a grievance was filed when the resident did not receive a shower for a week. Similarly, Resident 3, with a history of cerebral infarction and schizophrenia, was scheduled for showers on Mondays, Wednesdays, and Fridays but did not receive them consistently. The resident reported that staff documented refusals when, in fact, showers could not be given due to a lack of towels. Interviews with staff revealed that the facility faced issues with linen availability, which affected the ability to provide showers as scheduled. Certified Nursing Assistants reported that baths could not be given at times due to a lack of clean linens, and the Director of Nursing confirmed that there had been issues with linen availability. Despite these challenges, the facility did not adequately address the residents' preferences and needs for personal hygiene, leading to the deficiency.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident to the State Agency within the required time frame. According to the facility's policy, any alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, must be reported immediately, but not later than 2 hours if they involve abuse or result in serious bodily injury, or within 24 hours if they do not. The resident in question, who had diagnoses including intellectual disabilities, Alzheimer's disease, and dementia, was observed with a significant bruise around the left eye that had not been evaluated or reported in a timely manner. Interviews with staff revealed uncertainty about the cause of the bruise, with a CNA noting the injury was present after returning from days off, and an LPN suggesting a possible fall but finding no documentation to confirm this. The facility administrator admitted to completing a report to the state only after being prompted by the surveyor's inquiry, confirming that no prior report of the injury had been made. This delay in reporting violated the facility's policy and regulatory requirements for timely notification of injuries of unknown origin.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for a resident, identified as R6, who was admitted with multiple diagnoses including intellectual disabilities, Alzheimer's disease, dementia with agitation, generalized anxiety disorder, major depressive disorder, dysphagia, and a need for assistance with personal care. The deficiency was identified through a review of the facility's policy on abuse prevention, which mandates immediate reporting and investigation of any suspected abuse, mistreatment, or neglect. Despite this policy, the facility did not evaluate or report a bruise found on R6's left eye on two separate occasions. Interviews with staff revealed a lack of clarity and documentation regarding the incident. An LPN suggested that R6 might have fallen but could not find any documentation to support this claim. The facility's administrator confirmed that no incident report had been completed for the bruising and acknowledged that the staff did not follow the expected procedures for reporting and documenting such incidents. This lack of action and documentation led to the deficiency noted in the report.
Inaccurate Reporting of Direct Care Staffing Data
Penalty
Summary
The facility failed to accurately report direct care staffing data to CMS for the first quarter of Fiscal Year 2024. A review of the PBJ Report for Q1 2024 revealed that the facility triggered a one-star staffing rating due to excessively low weekend staffing, failure to submit PBJ data by the deadline, more than four days in the quarter without RN staffing hours, and failure to respond to or pass a CMS audit designed to discover discrepancies in PBJ data. Discrepancies were found between the total number of hours nursing staff worked on weekends and the total number of nursing hours reported to CMS. Interviews with the Director of Nursing (DON), the Administrator, and the Regional President revealed that the current leadership was unable to explain the discrepancies, as they were not in their positions during the period in question. The DON reported working weekends and weekdays to ensure coverage, and the Regional President acknowledged the one-star staffing rating and stated that the facility was currently in compliance with RN coverage and staffing. The former leadership, including the previous Administrator and DON, were no longer working at the facility, making it difficult to determine the baseline and the cause of the staffing shortages and inaccuracies in the PBJ reports submitted.
Infection Control Deficiency in Laundry Department
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in the laundry department, leading to potential cross-contamination of dirty and clean laundry. Observations during a tour revealed spider webs and a buildup of dust on walls, ceiling tiles, pipes, and behind washing machines and dryers. Additionally, there was a heavy accumulation of dust, dirt, and grime on pipes, electrical cords, and the floor behind the machines. Heavily soiled and dusty cloths were used as fillers around the air conditioning unit in the clean sorting and folding area. A pink bath pan under the handwashing sink was filled with dark-colored liquid, indicating a leak that had been present long enough for the liquid to overflow onto the floor, with unidentifiable black spots on the rim of the pan. Interviews with staff revealed that the facility was using agency staff for housekeeping and laundry. The Housekeeping Manager confirmed that staff were supposed to clean the laundry area daily, but acknowledged the presence of dust and other cleanliness issues. The Maintenance Director and Corporate Maintenance were unaware of the cleaning and maintenance issues in the laundry department until they reviewed pictures and confirmed the unsanitary conditions. The Administrator stated that her expectations were for the laundry department to be clean and sanitary, and mentioned that a new AC/heat unit was needed in the folding/sorting room, which required a capital expenditure request to corporate due to the cost exceeding $500.
Unsecured Unauthorized Medications Found in Residents' Rooms
Penalty
Summary
The facility failed to ensure that four residents did not have unsecured unauthorized medications stored at their bedside. Resident 3, who had diagnoses including Type 2 diabetes, schizophrenia, Alzheimer’s, and hypertension, was observed with medicated creams on her bedside table. She reported using the cream daily, although she had not been assessed to self-administer medications. Similarly, Resident 10, with diagnoses including gastro-esophageal reflux disease and mild cognitive impairment, had peroxide and mupirocin ointment in her bathroom. She stated that her wound nurse gave her the ointment to self-apply, but she had not been assessed for self-administration either. Resident 22, with chronic obstructive pulmonary disease and mild cognitive impairment, had oral tooth gel on his nightstand, which he reported using for mouth pain. He also had not been assessed for self-administration. Resident 27, with heart disease, Type 2 diabetes, and hypertension, had mouthwash and rubbing alcohol in her bathroom and artificial tears on her bedside table. She reported using these items without supervision, but she had not been assessed for self-administration either. During rounds with the Director of Nursing (DON) and an LPN, all medications and antiseptic products were confirmed in the residents' rooms. Both staff members were unaware of the medications and products. The DON reported that none of the residents were care planned or assessed to self-administer medications or antiseptic products. The DON removed the medications from the residents' rooms and noted that some items, like the artificial tears, should be kept at the nurse station. The DON also mentioned that the facility has a monitoring system called Angels Guardian Rounds to inspect rooms for unauthorized items, but she had not been in the residents' rooms lately. An LPN confirmed that the eyedrops were in Resident 27's room and denied leaving them there. She also stated that zinc ointment or any incontinent cream items should be placed in a secure place and not left at the bedside. The LPN reported being unaware of Resident 27 using the vaginal cream independently and mentioned that nurses would typically apply such creams for infection control. She also stated that nurses and certified nursing assistants were educated to place these items in a secure place after use.
Environmental Deficiencies in 100 Hall
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for residents in the 100 Hall. Observations revealed a loose handrail along the interior corridor, jagged and rough edges on the exit door frame, an old rusty inoperable heater attached to the wall, and chipped and scratched flooring near the dining area. These issues were confirmed by the Administrator and the Maintenance Director during walking rounds. Additionally, the Maintenance Director acknowledged that the handrail and flooring needed repairs, but approval from the corporate office was required for the flooring fix. Further observations identified environmental concerns in specific rooms and bathrooms. Room 13 had peeling paint exposing dirty tiles and scraped closet and bathroom doors. Room 10's bathroom floor tiles were stained with a dark brown sticky substance, and the bathroom door was damaged, preventing closure. Room 4 had scraped closet doors with protruding sharp jagged edges. The exit door frame had missing parts causing jagged sharp edges, and a wall-mounted heater near the exit door was covered with rust. Room 8's bathroom had two uncovered basins on the floor with dirt and debris, and dark wet coffee-colored stains coating the tiles near the commode. These issues were confirmed by the Maintenance Director, Administrator, and Housekeeping Supervisor, who acknowledged the environmental deficiencies and the need for repairs.
Failure to Implement Care Plan for Oxygen Administration
Penalty
Summary
The facility failed to implement the care plan for a resident (R17) related to oxygen administration. The resident was admitted with a diagnosis of chronic obstructive pulmonary disease (COPD) and shortness of breath. The care plan indicated that the resident required supplemental oxygen, with specific oxygen settings as ordered by the physician. However, during observations on two separate occasions, the surveyor noted that the resident's oxygen level was set at 4.5 L/M, which was not in accordance with the physician's order. This discrepancy was confirmed through interviews with the Director of Nursing (DON) and the MDS Coordinator, who both stated that the expectation was for nurses to monitor and ensure the oxygen is set at the correct level per the physician's order and to follow the resident's care plan. The facility's policy titled RAI/Care Planning Management emphasized the importance of conducting a comprehensive and accurate assessment of each resident's functional capacity and ensuring that care plans are accessible for clinical staff to facilitate care plan interventions. Despite this policy, the facility did not adhere to the care plan for R17, leading to the deficiency. The DON and MDS Coordinator acknowledged that the care plan was not followed, which resulted in the resident receiving an incorrect oxygen level.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to ensure that oxygen was administered as ordered by the physician for a resident with chronic obstructive pulmonary disease (COPD) and shortness of breath. The physician's order specified that the resident should receive oxygen at 2 liters per minute (L/M) continuously via nasal cannula. However, during an initial screening, the surveyor observed that the oxygen was set at 4.5 L/M. This discrepancy was confirmed by two Licensed Practical Nurses (LPNs) who were unaware of the correct oxygen setting as per the physician's order. The resident confirmed that she did not alter the oxygen settings herself, indicating that the staff failed to monitor and adjust the oxygen levels as required. Further interviews with the Director of Nursing (DON) and the MDS Coordinator revealed that the facility's policy and the resident's care plan both required the oxygen to be administered as ordered by the physician. The DON acknowledged that failing to adhere to the prescribed oxygen levels could put the resident at risk of adverse reactions, especially given her COPD diagnosis. The MDS Coordinator also emphasized that nurses are expected to follow the physician's orders and the resident's care plan, which was not done in this case.
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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