Gold City Health And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Dahlonega, Georgia.
- Location
- 222 Moore Drive, Dahlonega, Georgia 30533
- CMS Provider Number
- 115689
- Inspections on file
- 23
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Gold City Health And Rehab during CMS and state inspections, most recent first.
A resident with severe cognitive impairment but intact limb function, care planned to use a wheelchair and not to have restraints, was observed early one morning by two dietary staff seated or reclined in a Broda chair near the nurses’ station, appearing unable to move arms or legs and verbally expressing distress. One dietary aide believed the resident’s wrists were secured with Velcro, while the other reported the resident’s apparent immobility to nursing staff but did not escalate the concern to administration. Later that morning, an Infection Control LPN saw the resident reclined in a Broda chair, recognized it could function as a restraint, and directed transfer to a regular wheelchair, but did not identify or report an abuse allegation at that time. The dietary staff did not report their observations to their supervisor until two days later, at which point administration was notified and the incident was reported to the State Agency, contrary to facility policy and staff expectations that all suspected abuse or restraint use be reported immediately.
A resident with multiple chronic conditions, severe cognitive impairment, and documented use of a manual wheelchair was placed in a Broda chair without a prior PT assessment, despite facility expectations that such devices be evaluated through a therapy referral. The resident’s MDS and care plan reflected wheelchair use, limited mobility with supervision, and no use of restraints or chairs that prevent rising. An LPN admitted the resident had not been assessed for the Broda chair, a restorative CNA was unaware of its use and reported the resident used a regular wheelchair and could stand, and a PTA confirmed there was no PT referral and no observed Broda chair use. Leadership staff acknowledged that, even when used for comfort and positioning, a therapy assessment should have been completed before using the Broda chair.
A resident with severe cognitive impairment and a history of inappropriate sexual behavior was able to have unsupervised access to another resident, resulting in inappropriate physical contact and attempted kissing. The incident occurred when no staff were present at the nurses' station, and the affected resident was unable to disengage without staff intervention. This reflects a failure to prevent resident-to-resident abuse as required by facility policy.
A resident with multiple mental health diagnoses and a history of suicidal ideation did not have a comprehensive, person-centered care plan with specific interventions to ensure psychosocial well-being and safety. Despite documented incidents of self-harm and a care plan outlining certain precautions, observations revealed that potentially harmful items, such as clear trash liners, were accessible, and staff interviews showed inconsistent understanding of safety measures.
A resident with multiple medical and psychiatric diagnoses was provided with a bed rail without documented assessment, attempts at alternative interventions, or informed consent. Staff and administration confirmed that the required evaluation and interdisciplinary review were not completed prior to the installation of the bed rail.
The facility failed to maintain RN coverage for eight consecutive hours daily on specific dates, as revealed by staff interviews and Daily Nursing Staff Reports. The interim Administrator confirmed the requirement for RN coverage and acknowledged the potential for negative outcomes due to the absence of RNs, potentially affecting all 68 residents.
The facility failed to maintain the chemical level of the low temperature dishwasher, resulting in zero parts per million (PPM) concentration of chlorine, potentially affecting all 68 residents. A dietary aide continued to wash dishes without notifying anyone about the issue, and the dishwasher log was incomplete for several days. The Dietary Manager confirmed the sanitizer should have been at 50 PPM.
The facility failed to protect residents from mental, verbal, and physical abuse. A resident with no cognitive decline verbally harassed others, leading to a physical altercation, while another resident made inappropriate comments and was involved in verbal abuse incidents. Despite these issues, care plans were not updated with new interventions. Additionally, a resident with severe cognitive impairment struck another resident, highlighting the facility's failure to prevent abuse.
A resident with severe dementia and aggressive behaviors was involved in multiple altercations with other residents due to inadequate supervision and monitoring. Despite incidents of aggression, the facility failed to update the resident's care plan with new interventions, leading to repeated conflicts. Staff interviews confirmed insufficient monitoring, contributing to the deficiency.
A facility failed to accurately reflect a resident's Do Not Resuscitate (DNR) status in her medical records. Although the resident's paper chart clearly indicated a DNR order, her electronic medical record (EMR) and admission record incorrectly listed her as a full code, meaning CPR should be attempted. The resident was cognitively intact and had signed documents confirming her DNR status, but these were not accurately reflected in the EMR. The Assistant Director of Nursing confirmed the discrepancies during an interview.
The facility failed to report an abuse allegation within the required timeframe. A resident with severe cognitive impairments entered another resident's room, touched her inappropriately, and yelled at her. The incident was reported to a CNA and then to an LPN, but it was not communicated to the abuse coordinator until several hours later, as confirmed by the Administrator.
A resident reported being treated roughly by a CNA, including being pushed and having her wheelchair moved out of reach. The resident had scratches and bruises, but the facility's investigation did not document inquiries into these injuries. The CNA was suspended and later quit, but the investigation concluded that abuse could not be substantiated. The administrator acknowledged that the resident should have been asked about the injuries.
A facility failed to provide a resident and their responsible party with a written notice of transfer to a hospital, as required by policy. The resident, who had moderately impaired cognition, was hospitalized for medical reasons but did not receive the necessary documentation. The Business Office Manager acknowledged the omission, although the ombudsman was informed.
A facility failed to monitor a resident for adverse effects and behaviors related to the use of an antidepressant medication, as required by their policy. The resident, who was cognitively intact and diagnosed with bipolar and generalized anxiety disorders, was prescribed sertraline for depression. Despite the care plan's requirement to monitor for adverse reactions, no documentation was found in the resident's records. The ADON confirmed the lack of monitoring documentation.
A medication cart on the B Hall was left unattended and unlocked, allowing potential unauthorized access to medications. The cart contained residents' liquid medications and insulin vials and was out of the nurse's sight for about 17 minutes. An LPN admitted to forgetting to lock the cart, and the DON confirmed that staff had been educated on the importance of securing medication carts.
The facility did not fill in the daily census on the Daily Nursing Staff Report(s) from late July to late August 2024. This omission was confirmed by the interim Administrator and could cause uncertainty for visitors about the staff-to-resident ratio. The facility census was 68 residents.
Failure to Timely Report Suspected Restraint Use as Possible Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of possible abuse involving the use of restraints on a resident to the State Survey Agency, as required by facility policy and regulation. The resident involved had multiple diagnoses, including Down syndrome, cerebral palsy, type 2 diabetes mellitus, congestive heart failure, chronic atrial fibrillation, epilepsy, chronic kidney disease stage 3, anxiety, restlessness and agitation, lumbar compression fractures, abdominal distension, obstructive uropathy, and urogenital implants. The resident’s MDS showed severely impaired memory and decision-making but no impairment in upper or lower extremity function, and indicated that no restraints or chairs that prevent rising were in use. The care plan documented limited mobility, use of a wheelchair, and need for staff supervision for short ambulation. On the early morning in question, two dietary staff members arriving for day shift observed the resident seated or reclined in a Broda (medical) chair near the nurses’ station. One dietary staff member reported that the resident asked for tea and appeared to have immobile arms, and believed the resident’s wrists were secured with Velcro, though she was uncertain due to dim lighting. She also observed the resident in disposable underwear with a sheet over his waist. The other dietary staff member observed the resident reclined, covered with a white blanket, appearing unable to move his arms or legs, with only his head moving forward, and heard the resident say, “I am done, I am done.” This staff member stated she reported her observations to nursing staff, who told her the resident had been awake all night and would remain in the chair for a while. Neither dietary staff member reported their observations to administration at that time. Later that morning, an Infection Control LPN observed the resident reclined in a Broda chair with feet elevated and recognized that the reclined Broda chair could be considered a restraint, instructing another LPN to transfer the resident to his regular wheelchair. She stated she did not see restraints or distress. The two dietary staff did not bring their concerns to their supervisor until two days later during a morning meeting, at which time they were asked for written statements and the concern was then reported to administration. The Administrator was not notified until that point, and the Facility-Reported Incident was submitted to the State Agency only after this delayed internal reporting. Facility policies required all allegations of abuse, neglect, or exploitation, including potential restraint use, to be reported immediately to the Administrator and appropriate agencies, and staff interviews confirmed that all staff, including non-nursing staff, were expected to immediately report suspected abuse or restraint use, even if uncertain. The delay from the initial observations to notification of administration and reporting to the State Agency constituted the failure to timely report the suspected abuse.
Failure to Assess Resident Prior to Use of Broda Chair
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received an appropriate assessment before the use of a Broda chair, a specialized seating device. The facility could not provide a policy specific to assessment prior to use of mobility devices, and the existing Functional Impairment – Clinical Protocol only generally addressed assessment upon admission, with significant change, and periodically, including use of consultations and therapy evaluations to guide care planning. The resident involved had multiple diagnoses, including Down syndrome, unspecified cerebral palsy, type 2 diabetes mellitus, congestive heart failure, chronic atrial fibrillation, epilepsy, benign prostatic hyperplasia, chronic kidney disease stage 3, anxiety, restlessness and agitation, lumbar compression fractures, abdominal distension, obstructive uropathy, and urogenital implants. The most recent MDS showed severely impaired memory and cognitive skills for daily decision-making, but no impairment in upper or lower extremity function, use of a manual wheelchair for mobility, and no use of restraints, bed rails, bed alarms, or chairs that prevent rising. The care plan documented limited mobility with supervision for short ambulation distances and wheelchair use, and addressed fall risk and safety with interventions such as staff supervision and environmental safety measures. Staff interviews revealed that the Broda chair was used for the resident without a prior therapy assessment or documented PT referral. An LPN acknowledged that the resident had not been assessed for use of the Broda chair before it was used. A restorative CNA reported being unaware of the resident using a Broda chair and stated the resident used a regular wheelchair and was able and preferred to stand. A PTA explained that when a Broda chair is considered, nursing is expected to submit a PT referral for an assistive device evaluation, after which PT determines appropriateness and provides recommendations; she confirmed there was no PT referral for this resident and that she had never seen the resident in a Broda chair. During a joint interview with leadership staff, the LPN stated the Broda chair was used for comfort rather than mobility but acknowledged a PT referral should have been initiated, and the RN and Administrator agreed that an assessment should have been completed in accordance with policy. These findings show the resident used a Broda chair without the required assessment to determine appropriateness, need, and safe use.
Failure to Prevent Resident-to-Resident Abuse Due to Lack of Supervision
Penalty
Summary
The facility failed to prevent resident-to-resident abuse when one resident with a history of inappropriate sexual behavior and severe cognitive impairment was able to have unsupervised access to another resident. The resident with high-risk heterosexual behavior and a BIMS score indicating severe cognitive impairment was care planned for behavioral problems, including inappropriate sexual behavior, with interventions to protect others. Despite these interventions, the resident was observed by an LPN holding another resident's hand, attempting to kiss his hands and arms, and pulling on his arm while the other resident tried unsuccessfully to pull away. No staff were present at the nurses' station at the time, as CNAs were making rounds, allowing the incident to occur without immediate intervention. The second resident involved had diagnoses including Alzheimer's disease, dementia, and impaired cognitive function, and was care planned for self-care deficits, aggression, wandering, and resistive behaviors. The incident was witnessed by an LPN, who intervened to separate the residents and was assisted by another staff member. The lack of supervision and failure to implement effective interventions allowed the opportunity for the inappropriate contact to occur, constituting a failure to protect residents from abuse as required by facility policy.
Failure to Develop and Implement Comprehensive Care Plan for Resident with Suicidal Ideation
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan with specific interventions to ensure the psychosocial well-being and safety of a resident with multiple mental health diagnoses, including schizoaffective disorder, bipolar disorder, major depressive disorder, anxiety disorder, and a history of suicidal ideation and attempts. Despite the resident being cognitively intact and having a care plan that included interventions such as 15-minute safety checks, use of only plastic silverware, placement in a room with a roommate, and removal of potentially harmful items, there were lapses in the execution and specificity of these interventions. Documentation revealed that the resident had recent incidents of self-harm, including drinking hand sanitizer and attempting to suffocate herself with a plastic bag. Observations showed that clear trash liners, which could pose a risk, were accessible in both the resident's and roommate's trash cans. Staff interviews indicated a lack of consistent understanding regarding the appropriateness of trash liners in the resident's environment. The facility's policy required comprehensive care plans with measurable objectives and timeframes, but the care plan for this resident did not adequately address all identified risks or ensure staff were fully informed and consistent in implementing interventions.
Failure to Assess and Document Alternatives Prior to Bed Rail Installation
Penalty
Summary
The facility failed to ensure that a resident was properly evaluated for bed rail use and that alternative measures were attempted prior to the installation of bed rails. According to the facility's policy, the use of bed rails is prohibited unless specific criteria are met, including the use of alternatives, an interdisciplinary evaluation, a resident assessment, and informed consent. For one resident with diagnoses including cerebral palsy, schizoaffective disorder, bipolar disorder, major depressive disorder, anxiety disorder, suicidal ideations, and paraplegia, there was no documentation of an initial bed rail assessment, alternatives tried, or consent for bed rail use. The resident was noted to be cognitively intact based on a Brief Interview for Mental Status (BIM) score of 15. Observations revealed a bed rail in the lowered position on the right side of the resident's bed, with the bed pushed against the wall on the left side. Staff interviews confirmed the presence of the bed rail and acknowledged that the required assessment, documentation of alternatives, and informed consent were not completed prior to installation. The Administrator and DON were unable to explain how the required documentation and interdisciplinary review were missed.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to maintain Registered Nurse (RN) coverage for eight consecutive hours seven days a week on specific dates, namely 8/10/2024, 8/11/2024, 8/24/2024, and 8/25/2024. This deficiency was identified through staff interviews and a review of the facility's Daily Nursing Staff Reports, which indicated the absence of RN coverage during each shift on the mentioned dates. The Administrator, who has been interim since July 2024, confirmed the requirement for RN coverage and acknowledged the potential for negative outcomes due to the lack of RN presence. This failure had the potential to leave all 68 residents without necessary medical assistance that only an RN could provide.
Failure to Maintain Dishwasher Sanitizer Levels
Penalty
Summary
The facility failed to maintain the chemical level of the low temperature dishwasher at a level that would sanitize soiled dishes, potentially affecting all 68 residents. During an observation, a dietary aide was seen running dishes through the dishwasher, which was not dispensing any sanitizer into the rinse cycle. The test strip used to check the sanitizer level did not change color, indicating a zero parts per million (PPM) concentration of chlorine. Despite this, the aide continued to wash dishes without notifying anyone about the issue. The facility's policy required the sanitizer level to be between 50 and 100 PPM, and the dishwasher log should have been completed three times daily to ensure proper maintenance. Further investigation revealed that the sanitizer level had not been checked since the morning, and the dishwasher log was incomplete for several days. The dietary aide admitted that she was supposed to inform the Dietary Manager if the sanitizer was not at the correct level but planned to do so only after the manager arrived the next morning. The Dietary Manager later confirmed that the sanitizer should have been at 50 PPM and acknowledged that the staff should not have used the dishwasher when the sanitizer level was zero.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from mental and verbal abuse, as evidenced by incidents involving several residents. Resident R19, who had no cognitive decline, was involved in multiple incidents of verbal harassment. R19 accused R53 of stealing, leading to a physical altercation where R53 struck R19 with magazines. Additionally, R19 made inappropriate remarks about R11's body, which were overheard by a staff member. Despite these incidents, R19's care plan was not updated with new interventions to address his behaviors. Resident R16, who was cognitively intact, also displayed verbally aggressive behaviors. R16 was reported to have asked R53 if she wanted to be raped, a statement that was overheard by a nurse. R16 admitted to making the inappropriate comment and apologized. Furthermore, R16 was accused of verbally abusing residents R122 and R71 by calling them derogatory names. Despite these incidents, R16's care plan did not include new interventions to manage her behaviors. The facility also failed to protect a resident from physical abuse. R53, who had severe cognitive impairment, struck R48 with a plastic plate during a disagreement over bingo prizes. R48, who had moderate cognitive decline, was not injured but the incident highlighted the facility's inability to prevent physical altercations. The facility's policies on abuse prevention were not effectively implemented, as evidenced by the lack of updated care plans and interventions for residents involved in these incidents.
Inadequate Supervision Leads to Resident Altercations
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents involving a resident with severe dementia, delusions, and paranoid schizophrenia, who exhibited aggressive behaviors towards other residents. The resident, identified as R6, had a history of negative behaviors and was involved in multiple altercations with other residents, including hitting another resident with a tray lid and striking another resident in the face. Despite these incidents, the facility did not implement new interventions in R6's care plan to address these behaviors. In one incident, R6 was involved in an altercation with another resident, R23, after being run into by R23's wheelchair. The facility's Activities Director witnessed the incident but was unable to prevent it. Another altercation occurred when R6 entered the wrong room and began touching another resident, R36, due to confusion after a room change. The facility did not provide adequate monitoring or redirection for R6, which contributed to these incidents. The facility's failure to provide continuous monitoring and appropriate interventions for R6's aggressive behaviors resulted in repeated altercations with other residents. Staff interviews confirmed that monitoring was insufficient, and the facility did not maintain the necessary supervision to prevent these incidents. The lack of timely psychiatric consultation and failure to update care plans further contributed to the deficiency.
Failure to Accurately Reflect DNR Status in Medical Records
Penalty
Summary
The facility failed to ensure that a resident's medical record accurately reflected her request to not have cardiopulmonary resuscitation (CPR) in the event of cardiopulmonary failure. The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15, had a documented Do Not Resuscitate (DNR) order in her paper chart. However, her electronic medical record (EMR) and admission record inaccurately indicated she was a full code, meaning CPR should be attempted. The resident's paper chart contained a sticker indicating DNR and a signed document titled "Do Not Resuscitate for Resident with Decision Making Capacity," which clearly stated that CPR was not to be initiated. Additionally, the Advanced Directive Checklist signed by the resident also had the DNR order check marked. Despite these clear indications in the paper record, the EMR and admission record failed to reflect the resident's wishes accurately. The Assistant Director of Nursing (ADON) confirmed the inaccuracies in the EMR and paper chart during an interview.
Delayed Reporting of Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse within the required two-hour timeframe for two residents, R6 and R36, as per their policy on Abuse, Neglect, and Exploitation. R6, who has severe cognitive impairments including Alzheimer's disease and schizophrenia, allegedly entered R36's room early in the morning, touched her inappropriately, and yelled at her. R36, also severely cognitively impaired, reported the incident to a CNA, who then informed an LPN. However, the incident was not reported to the abuse coordinator until five and a half hours later, which was confirmed by the facility's Administrator. The incident occurred when R6, in a wheelchair, entered R36's room and began touching her and pulling off her blankets. The CNA who witnessed the event removed R6 from the room and later reported the incident to the charge nurse. However, the report was not clearly communicated, leading to a delay in notifying the appropriate authorities. The facility's investigation included a handwritten statement from the CNA, who admitted to not ensuring the nurses heard the report. The Administrator acknowledged the delay in reporting the incident, which was not in compliance with the facility's policy.
Failure to Investigate Resident Abuse Allegation Thoroughly
Penalty
Summary
The facility failed to thoroughly investigate an allegation of staff-to-resident abuse involving a resident who reported being treated roughly by a CNA. The resident, who was cognitively intact, reported that the CNA was rude, pushed her wheelchair out of reach, and made her lie in her own urine. The resident also reported being shoved, which was immediately reported to the abuse coordinator, and a police report was made. The resident was assessed for injuries, with scratches on her wrists and bruising on her shins noted. However, the investigation did not document any inquiry into these injuries. The facility's investigation concluded that abuse could not be substantiated, and the CNA involved was suspended but quit shortly after. Despite a follow-up interview with the resident, there was still no documentation that the resident was asked about the scratches and bruises. The administrator, who was not employed during the investigation, acknowledged that the resident should have been asked about these injuries. The lack of thorough investigation into the resident's reported injuries represents a deficiency in the facility's handling of the abuse allegation.
Failure to Provide Written Transfer Notice
Penalty
Summary
The facility failed to provide a resident and their responsible party with a written notice of transfer and the reasons for the transfer, as required by their policy. This deficiency was identified during a review of the facility's policy titled 'Transfer and Discharge,' which mandates that a transfer notice be provided to the resident and representative when a discharge is initiated by the facility for medical reasons to an acute care setting such as a hospital. The review of the electronic medical record (EMR) and hard chart for one resident revealed no transfer/discharge notices were provided, despite the resident being hospitalized. The resident in question, who had moderately impaired cognition, was readmitted to the facility with multiple diagnoses, including acute respiratory failure and chronic kidney failure. During an interview, the resident confirmed hospitalization but could not recall receiving any written notices. The Business Office Manager admitted that no written transfer/discharge notice was sent to the resident or their responsible party, although the ombudsman was notified. This oversight had the potential to leave the resident and their responsible party unaware of the transfer and its reasons.
Failure to Monitor Adverse Effects of Antidepressant Medication
Penalty
Summary
The facility failed to monitor for adverse consequences and behaviors related to the use of antidepressant medication for one resident, identified as R24, who was part of a sample of 43 residents reviewed for unnecessary medications. The facility's policy on antipsychotic medication use, dated July 2022, requires staff to observe, document, and report any side effects or adverse consequences of such medications to the attending physician. However, a review of R24's records, including the Medication Administration Record (MAR), Treatment Administration Record (TAR), and the TASKS tab, revealed no documentation of monitoring for adverse consequences or behaviors. R24 was admitted with diagnoses including bipolar disorder and generalized anxiety disorder and was prescribed sertraline HCl (Zoloft), an antidepressant, for depression. Despite the care plan's directive to monitor and document any adverse reactions to psychotropic medications, there was no evidence of such monitoring in the resident's records. During an interview, the Assistant Director of Nursing (ADON) confirmed the absence of documentation for monitoring behaviors or adverse consequences, acknowledging that such monitoring should have been documented.
Medication Cart Security Breach
Penalty
Summary
The facility failed to ensure the security of a medication cart on the B Hall, which was left unattended and unlocked, allowing potential unauthorized access to medications. During an observation, the cart was found between rooms B5 and B78, out of the nurse's sight, and unlocked. Inside the cart were residents' liquid medications and insulin vials, easily accessible to anyone passing by. Two residents were noted to be within close proximity to the unlocked cart, which remained unsecured for approximately 17 minutes until the Assistant Director of Nursing locked it. Interviews with staff revealed that an LPN admitted to forgetting to lock the cart due to moving too quickly to another hall. The LPN acknowledged the importance of keeping the cart locked to ensure resident safety. The Director of Nursing confirmed that medication carts are expected to be locked when not in use or out of sight and mentioned that nursing staff had been educated on this requirement, although she was unsure of the last training session.
Failure to Indicate Daily Census on Nursing Staff Reports
Penalty
Summary
The facility failed to indicate the daily census on the Daily Nursing Staff Report(s) from 7/29/2024 through 8/26/2024. This omission was identified during a review of the reports provided by the Administrator. The reports, which are required to be posted daily for nursing homes participating in Medicare and Medicaid programs, contained a space for the facility census, but this information was not filled in. The absence of this information could lead to uncertainty for resident family, friends, or other visitors regarding the ratio of nursing staff to residents. The facility census at the time was 68 residents. During an interview, the interim Administrator, who had been in the role since July 2024, confirmed that the census should have been indicated on the posted reports.
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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