Hill Haven Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Commerce, Georgia.
- Location
- 880 Ridgeway Road, Commerce, Georgia 30529
- CMS Provider Number
- 115710
- Inspections on file
- 19
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Hill Haven Nursing Home during CMS and state inspections, most recent first.
A resident with Parkinson's disease and limited mobility was not protected from another resident with dementia and a history of physical and verbal aggression. The roommate threw food and a tray at her, threatened to kill her, and staff interviews confirmed prior aggressive behavior and threats toward other residents. The resident stated she felt unsafe and feared being attacked, while staff acknowledged the roommate's behavior and the impact on the resident.
The facility failed to timely report an allegation of resident-to-resident verbal and physical abuse to the SSA. A resident with intact cognition reported that another resident threw a tray at her, got food on her, got in her face, and threatened to kill her; the resident said she did not feel safe. The other resident had documented physical and verbal behaviors toward others. The Administrator stated the incident was not reported because it was determined not to meet the definition of abuse, and only a verbal investigation was conducted with no documentation available.
The facility failed to ensure proper labeling and storage of food items in the kitchen, as required by their policy. Observations revealed undated waffles, an open bag of onion rings, an unsealed box of fish sticks, and open containers of sausage and eggs. The Dietary Kitchen Manager confirmed that staff were expected to label and date food items, but this was not consistently done, potentially affecting 55 out of 59 residents receiving an oral diet.
The facility did not establish a water management program as part of its infection prevention and control program, despite it being a requirement in their policy. The absence of this plan was confirmed by the Administrator, who had recently started working at the facility and planned to address the issue in an upcoming QAPI meeting. The facility had 59 residents at the time.
A facility failed to report a sexual abuse allegation involving a resident with severe cognitive impairment within the required time frame. The incident involved a CNA allegedly engaging in inappropriate conduct with the resident. The DON did not complete necessary notifications or documentation, and the Medical Director was not properly informed. The accused CNA was sent home, and the reporting CNA was moved to a different hall. The Administrator expected immediate reporting, but the previous Administrator had not enforced contacting law enforcement.
A facility failed to thoroughly investigate a sexual abuse allegation involving a resident with severe cognitive impairment. The investigation lacked proper documentation, with missing witness statements and no confirmation of notification to the Medical Director. The Director of Nursing did not complete a required skin assessment, and local police were not contacted. The accused CNA was suspended, but the Human Resource Director confirmed no findings were documented in employee files. The Administrator noted previous failures in reporting procedures.
The facility failed to develop comprehensive care plans for two residents receiving respiratory care. One resident with pneumonia and respiratory failure had physician orders for nebulizer treatments, but these were not included in the care plan. Another resident with anemia, coronary artery disease, and heart failure had orders for nebulizer therapy, but the care plan only included oxygen therapy. Interviews confirmed the absence of these care plans.
The facility failed to maintain safe water temperatures in resident rooms, with temperatures exceeding the policy limit of 120 degrees Fahrenheit in five rooms. Despite monthly checks showing acceptable ranges previously, recent observations revealed dangerously high temperatures, though no residents were injured.
A facility failed to properly store a nebulizer mouthpiece for a resident with severe cognitive impairment and respiratory issues, leaving it unbagged and exposed, which could lead to infections. Staff interviews confirmed awareness of proper storage procedures, but the equipment was found uncovered multiple times. The DON noted a lack of a logging system for maintenance tasks.
Failure to Protect Resident from Roommate Abuse
Penalty
Summary
The facility failed to protect one resident from physical and verbal abuse by another resident. The cited resident had Parkinson's disease, anxiety, depression, suicidal ideations, intact cognition on MDS, and limited physical mobility related to neurological deficits, poor balance, coordination, and weakness. The other resident had diagnoses including dementia with behavioral disturbance, severe dementia with psychotic disturbance, depression, psychosis, and mood disorder, and her care plan identified a potential for physical and verbal aggression due to dementia, anger, and poor impulse control. On the day of the incident, the resident reported that her roommate threw a tray at her, food got all over her, and the roommate got in her face and stated that she would kill her. The resident stated she did not feel safe and requested that the roommate be moved to another room. The social worker documented the report and notified leadership, and the decision was made to move the roommate. The resident later stated that she had repeatedly asked staff to provide the roommate's meals in the dining room under supervision, but trays continued to be delivered to the room. Staff interviews confirmed the roommate's aggressive behavior. A CNA stated food was on the floor and between the resident's legs in her wheelchair, the tray was on her bed, and the resident was upset. Another CNA stated the roommate threw food, the resident was frightened because of her Parkinson's disease and inability to protect herself due to balance problems, and that the roommate had previously thrown dessert at her and had hit her before. The social service director and medical director both stated they were aware of the roommate's verbal and physical aggression and threatening statements toward residents, and the medical director confirmed the resident feared she would be attacked.
Failure to Timely Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of resident-to-resident verbal and physical abuse to the State Survey Agency within the required time frame for one of 36 sampled residents. Review of the facility policy stated that all reports of resident abuse, neglect, exploitation, or misappropriation are to be reported to local, state, and federal agencies as required, and that allegations involving abuse or bodily injury are to be reported immediately, defined as within two hours. The deficiency involved two residents: one resident with a BIMS score of 15, indicating intact cognition, and another resident whose MDS documented that the interview was not completed or unsuccessful and who exhibited physical and verbal behaviors toward others for one to three days. Progress notes documented that the cognitively intact resident reported that the other resident threw a tray at her, got food all over her, got in her face, and stated that she would kill her. The resident stated she did not feel safe and requested that the other resident be moved to another room. The other resident’s progress note documented aggressive behavior toward the roommate and that the incident had been reported. A facility investigation summary stated the incident was not reportable to the state because it did not meet the definition of abuse, citing no willful intent to inflict harm and no physical or mental harm. During interview, the Administrator stated the incident was not reported to the State because it was determined not to meet abuse criteria, and that only a verbal investigation was conducted with several staff members, with no documentation available for review.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to ensure that food items stored in the main kitchen were labeled, dated, and properly stored, as required by their policy titled 'Food Receiving and Storage.' During a tour of the kitchen, several issues were identified, including a sleeve of waffles in the walk-in freezer that was undated, a half bag of onion rings left open in a box without a label or date, a five-pound box of frozen fish sticks that had been opened and not resealed, and two open containers containing sausage and frozen eggs. These observations indicate a lack of adherence to the facility's policy, which mandates that all foods stored in the refrigerator or freezer be covered, labeled, and dated. The Dietary Kitchen Manager (DKM) confirmed during an interview that kitchen staff were expected to label and date each food item received for the facility and properly store food items after opening them. The DKM acknowledged the deficiency and stated that it was her expectation for each staff member to comply with these requirements. The failure to follow these procedures had the potential to affect 55 out of 59 residents receiving an oral diet, as the improperly stored food items could compromise food safety.
Failure to Establish Water Management Program
Penalty
Summary
The facility failed to establish a water management program as part of its overall infection prevention and control program, which is a requirement according to their policy titled 'Infection Prevention and Control Program' revised on 10/28/2022. The policy explicitly states that a water management program should be in place, but upon review, it was found that the facility did not have an established Water Management Plan. This deficiency was confirmed during an interview with the Administrator, who acknowledged the absence of the plan. The Administrator, who had started working at the facility two weeks prior, identified this issue and planned to address it in the upcoming Quality Assurance Performance Improvement (QAPI) meeting. The facility had a census of 59 residents at the time of the survey.
Failure to Timely Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident, identified as R59, to the State Agency and other officials within the required time frame. The facility's policy mandates immediate reporting, defined as within two hours for allegations involving abuse or serious bodily injury. The incident involved a note received by a CNA, suggesting inappropriate sexual conduct by another CNA with R59, a resident with severe cognitive impairment and multiple diagnoses including cerebral palsy and epilepsy. Despite the policy, the Director of Nursing (DON) did not complete the necessary notifications or documentation, and the Medical Director was not properly informed. Interviews revealed that the accused CNA was sent home, and the reporting CNA was moved to a different hall. The DON did not conduct a skin assessment as documented and failed to notify local law enforcement. The Medical Director was not aware of the incident, and the Human Resource Director confirmed that no investigation findings were placed in the employee files. The Administrator expected immediate reporting of such incidents, but the previous Administrator had not enforced contacting law enforcement, leading to a deficiency in the facility's response to the allegation.
Inadequate Investigation of Sexual Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation into allegations of sexual abuse involving a resident, identified as R59, who has severe cognitive impairment and multiple medical conditions including cerebral palsy and epilepsy. The facility's policy requires all allegations to be thoroughly investigated, with witness statements obtained in writing, signed, and dated. However, nine out of 20 staff interviews lacked names and/or dates, and the investigation was not properly documented. The Director of Nursing (DON) did not complete a skin assessment as noted in the nurse's notes, and there was no confirmation of notification to the Medical Director. Additionally, the local police were not contacted, and the DON believed the allegations were merely rumors. The incident report indicated that a Certified Nursing Assistant (CNA) was accused of inappropriate behavior with R59, leading to the suspension of the accused CNA. The Human Resource Director confirmed that no investigation findings were placed in the employee files. The Administrator expected immediate reporting of abuse allegations, but the previous Administrator did not ensure law enforcement was contacted. The DON and Administrator's interviews revealed inconsistencies in the investigation process, and the facility did not adhere to its policy for handling such allegations.
Failure to Develop Comprehensive Care Plans for Respiratory Therapy
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans for two residents receiving respiratory care, specifically for nebulizer therapy for one resident and oxygen therapy for another. Resident R10, who had diagnoses of pneumonia and respiratory failure, had physician orders for nebulizer treatments, but these were not included in the care plan. The care plan only addressed potential impaired gas exchange related to congestive heart failure and oxygen therapy as needed for shortness of breath, omitting the necessary nebulizer therapy. Similarly, Resident R13, diagnosed with anemia, coronary artery disease, and heart failure, had physician orders for nebulizer therapy, but the care plan only included oxygen therapy as needed for shortness of breath, without addressing the nebulizer therapy. Interviews with the unit nurse and the Director of Nursing confirmed the absence of these care plans, acknowledging that all care areas, including medications, diagnoses, and treatments, should be included in the care plans.
Unsafe Water Temperatures in Resident Rooms
Penalty
Summary
The facility failed to maintain safe water temperatures in resident rooms, leading to potential accident hazards. During an inspection, water temperatures in five resident rooms were found to be significantly above the facility's policy limit of 120 degrees Fahrenheit, with measurements reaching as high as 137 degrees Fahrenheit. This discrepancy was observed despite the facility's policy requiring maintenance staff to regularly check and log water temperatures to ensure they remain within safe limits. The maintenance director confirmed that water temperature checks were conducted monthly, and the facility's logs indicated that previous checks showed temperatures within the acceptable range. However, the recent observations revealed a failure to maintain these standards, as several rooms had dangerously high water temperatures. Fortunately, no residents sustained burn injuries due to the elevated water temperatures at the time of the inspection.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for a resident receiving respiratory care. Specifically, the facility did not properly store the nebulizer mouthpiece for a resident with severe cognitive impairment, pneumonia, and respiratory failure. The resident's treatment plan included the use of a nebulizer for shortness of breath and wheezing. However, observations revealed that the nebulizer jar and mouthpiece were left unbagged and exposed to the environment on the resident's bed and bedside, which could potentially lead to respiratory infections. Interviews with facility staff, including a CNA and the DON, confirmed awareness of the proper storage procedures for respiratory equipment, which involves storing the equipment in a clear plastic bag when not in use to prevent infections. Despite this knowledge, the nebulizer mouthpiece was found uncovered on multiple occasions. The DON acknowledged that the night shift staff were responsible for ensuring proper storage and maintenance of respiratory equipment, but there was no logging system in place to track these tasks, contributing to the oversight.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
