Muscogee Manor & Rehabilitation Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Columbus, Georgia.
- Location
- 7150 Manor Road, Columbus, Georgia 31907
- CMS Provider Number
- 115351
- Inspections on file
- 20
- Latest survey
- February 22, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Muscogee Manor & Rehabilitation Ctr during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and diagnoses including bipolar disorder and dementia was observed with a blue pill floating in water on the bedside table after an LPN had administered divalproex sodium. The resident had no documented self-administration assessment or care plan, and the Unit Manager stated staff are expected to remain in the room to ensure residents swallow medications before leaving.
Private resident information was left visible in resident rooms and on a medication cart. Signs with clinical instructions were posted in the rooms of three residents, including one with severe cognitive impairment and renal disease, one with severe cognitive impairment and a colostomy, and one with a feeding tube and malnutrition; the records did not show that the residents or representatives requested the signage. In addition, an RNS left a laptop screen open on a med cart, allowing resident information to remain visible until staff returned.
Incomplete Care Planning for Hypertension and Oxygen Therapy: The facility failed to develop and/or implement comprehensive care plans for two residents. One resident with HTN had no care plan for BP management or metoprolol parameters despite low HR readings and a medication order for metoprolol. Another resident receiving oxygen for emphysema and asthma was observed at the wrong flow rate and without the ordered humidifier bottle, even though the care plan addressed oxygen therapy and staff confirmed the physician orders.
Insulin protocol and administration errors were identified for two residents with DM and severe cognitive impairment. For one resident, the MAR showed FSBS results below 50 mg/dl, but the MD was not notified as ordered and the recheck results were not documented. For another resident, an LPN did not hold the insulin pen in place long enough after injection, which could prevent the full dose from being delivered.
Oxygen Therapy Not Provided as Ordered: A resident with emphysema, asthma, and acute respiratory distress was ordered oxygen at 4 LPM via NC with tubing and humidifier changes every Monday. Staff observed the resident receiving oxygen at 3.5 LPM instead of 4 LPM, and later at 4 LPM but without the ordered humidifier bottle attached and in use. An LPN confirmed the missing humidifier, and the DON and Administrator confirmed staff were expected to follow the physician orders.
Failure to Check Vital Signs Before Metoprolol Administration: An LPN administered metoprolol to a resident with HTN without checking pulse or BP first. The resident had moderate cognitive impairment, and record review showed several prior HR readings below 60 bpm. The ADON, DON, and pharmacist stated that metoprolol should be monitored for HR and BP effects, and staff noted that parameters should be obtained from the MD for certain meds such as metoprolol.
Glucose test strips in two medication carts were found without open dates. An LPN confirmed the missing dates during observation, and the facility’s blood sugar checklist stated strips expire 3 months after first use. The ADON and DON both stated open dates should be placed on glucometer strip bottles when opened, and the DON noted that missing dates could result in inaccurate blood sugar readings.
The facility failed to properly label, store, and dispose of food items, potentially affecting 85 residents. Observations revealed unlabeled and expired food in the cooler, freezer, and pantry, with improper sealing and storage practices. Interviews with staff, including the FNM and LPN, indicated a lack of oversight and responsibility for managing food labeling and disposal, contributing to the deficiency.
A facility failed to provide a resident or their representative with written information about their rights to accept or refuse treatment and advance directives. The resident, with conditions like anoxic brain damage and protein calorie malnutrition, was on hospice care with a DNR order. Interviews revealed that the process for providing this information was not followed, as the advance directive form was not completed or signed.
A facility failed to submit a PASRR Level II for a resident with mental health diagnoses, including dementia and psychosis. The resident's diagnoses required a Level II screening to ensure appropriate care, but the facility lacked a PASRR policy, leading to a delay. Interviews revealed confusion among staff about the PASRR process and responsibilities, contributing to the oversight.
The facility failed to implement care plans for two residents regarding meal intake monitoring and did not develop a care plan for oxygen use for another resident. One resident with severe cognitive impairment had missing meal intake documentation, while another with little cognitive impairment also lacked consistent meal intake records. Additionally, a resident with COPD had no care plan for oxygen use, and their oxygen was set higher than ordered. Staff interviews confirmed the responsibilities for documentation and adherence to physician orders were not met.
A resident with severe cognitive impairment and a history of wandering eloped from a COVID unit due to an inoperable door alarm. The resident was moved from a locked dementia unit, and despite the facility's policy on accident prevention, the alarm system failed, allowing the resident to exit. The resident was found outside and returned by police, highlighting a lapse in supervision and safety measures.
A resident with chronic respiratory and heart conditions was observed receiving oxygen at 2.5 LPM instead of the physician-ordered 2 LPM. Staff interviews revealed that the respiratory therapist adjusted the oxygen level without obtaining a new physician order, contrary to facility policy. The MDS Coordinator had not completed a detailed care plan for the resident's oxygen therapy, and the DON expected staff to adhere strictly to physician orders.
The facility failed to prepare pureed food according to established procedures, affecting residents on a pureed diet. A staff member prepared pureed spaghetti without using a formal recipe, relying on experience and imprecise measurements. The Food and Nutrition Manager and Administrator were aware of the issue, which had the potential to affect 13 residents.
Medication Left Unswallowed at Bedside
Penalty
Summary
The facility failed to ensure that one resident, R57, swallowed a medication before the nurse left the room. R57 had been admitted in 2016 and had diagnoses including unspecified bipolar disorder with psychotic features, vascular dementia, bipolar disorder, tremor, and dementia in other diseases classified elsewhere. The quarterly MDS dated 02/03/2026 showed a BIMS score of 03, indicating severe cognitive impairment. The current comprehensive care plan revised 02/19/2026 did not include a plan for self-administration of medication, and the electronic medical record showed no evidence of an assessment for self-administration. During observation on 02/20/2026, R57 was sitting up in bed with a clear small cup of water and a blue pill floating in it on the bedside table. When asked about the cup contents, R57 stated it was a pill and continued looking at it. The cup with the pill remained on the bedside table during a later observation. The LPN stated she had given the blue pill, identified as divalproex sodium, to R57 that morning and was not sure why the resident did not swallow it. The Unit Manager stated staff are expected to stay in the resident's room to ensure residents swallow medication before leaving, and confirmed that R57 was not assessed for self-administration of medications.
Private resident information left visible in rooms and on a medication cart
Penalty
Summary
The facility failed to keep resident medical information private and confidential when clinical signage was posted in the rooms of three residents and when a medication cart laptop screen was left open and visible. The report states that the facility’s policies required resident health information to remain private, that MARs and electronic health record information must not be visible when not in direct use, and that only authorized staff should access the EMR system. Surveyors observed that private information was visible to unauthorized individuals in resident rooms and at the medication cart. For one resident with severe cognitive impairment, end-stage renal disease, type 2 diabetes, and a mechanically altered diet, signs were posted above the bed stating no milk products or pudding and listing aspiration precautions. The record did not show that the resident or representative requested the signage, and the resident was unable to answer questions about it. For another resident with severe cognitive impairment, ostomy status, colostomy care orders, and diagnoses including cognitive communication deficit and intellectual disabilities, signs were posted next to the bed stating the resident had a colostomy bag and needed it changed when full, along with a turning schedule. The record did not show that the resident or representative requested the signage, and the resident was unable to answer questions about it. For a third resident with a feeding tube and mild protein-calorie malnutrition, a sign was posted behind the head of the bed stating the resident was a tube feeder and that the head of the bed should be elevated at all times. The record did not show that the resident or representative requested the signage, and the resident was unable to answer questions about it. In addition, an RNS left a laptop screen open on a medication cart and walked away, leaving resident information visible while staff passed by. The RNS confirmed the screen was not locked and stated that anyone could see the resident information, and the DON and ADON stated that laptop screens were expected to be locked when not in use.
Incomplete Care Planning for Hypertension and Oxygen Therapy
Penalty
Summary
The facility failed to develop and/or implement a comprehensive care plan related to oxygen therapy and medication parameters for two residents. The facility policy titled Care Plan Policy stated the Care Plan Coordinator was responsible for timely review of a resident’s status and any change in needs following a hospital stay or other unexpected event, and for ensuring concerns or changes were updated in the care plan. Survey findings identified that the deficient practice involved R62 and R70 and was noted to have the potential to increase the risk of clinical complications for both residents. R62 was re-admitted to the facility with hypertension and had a Quarterly MDS documenting hypertension as an active diagnosis. The comprehensive care plan revised 01/16/2026 contained no documented evidence of a care plan for hypertension. Physician orders dated 12/23/2025 included metoprolol tartrate 50 mg twice daily for hypertension. During medication administration observation on 02/21/2026, an LPN administered metoprolol to R62 and there was no parameter for the medication. The LPN stated metoprolol was not to be administered if the resident’s heart rate was less than 60 and confirmed the resident had heart rate readings below 60 on a few occasions. The record review showed the last set of vital signs was on 02/19/2026. The NM, MDS Coordinator, and DON each confirmed there was no hypertension care plan for R62. R70 had diagnoses including emphysema, asthma, and acute respiratory distress, and the Annual MDS documented that the resident was receiving oxygen. Physician orders dated 02/03/2025 directed oxygen at 4 LPM via nasal cannula day and night for emphysema and asthma, and tubing and humidifier changes every Monday day shift. The care plan revised 02/05/2025 included oxygen therapy with an intervention to administer oxygen and monitor O2 saturation as ordered. However, observations on 02/20/2026 showed R70 receiving oxygen at 3.5 LPM instead of the ordered 4 LPM, and no humidifier bottle attached to the concentrator. On 02/21/2026, R70 was observed receiving oxygen at 4 LPM, but again without a humidifier bottle attached and in use. An LPN confirmed the oxygen was at the correct rate during the later observation but also confirmed the humidifier bottle was not attached per physician orders. The DON, Administrator, and MDS Nurse confirmed staff were expected to ensure the resident received oxygen at the correct flow rate and with a humidifier bottle according to the physician orders.
Insulin Protocol and Administration Errors
Penalty
Summary
The facility failed to follow the physician-ordered insulin protocol for two residents receiving insulin. For one resident with diabetes mellitus and severe cognitive impairment, the record showed physician orders to call the MD for finger stick blood sugar results below 50 mg/dl, but the MAR documented blood sugar results of 46 and 43 with no evidence that the physician was notified. The ADON stated the nurses gave juice and rechecked the blood sugar, but the recheck results were not documented, and the physician was not called as ordered. The facility also failed to accurately administer insulin from a pen device for another resident with diabetes mellitus and severe cognitive impairment. During observation of medication administration, an LPN did not keep the insulin pen in place for at least 10 seconds after pressing the button and removed it too quickly. The LPN acknowledged that removing the pen too soon could allow insulin to spill out and prevent the resident from receiving the correct dose. The ADON confirmed the insulin pen should be held in place for at least 10 seconds so the full dose is delivered.
Oxygen Therapy Not Provided as Ordered
Penalty
Summary
The facility failed to ensure that R70 received oxygen therapy in accordance with physician orders. R70 had diagnoses including emphysema, asthma, and acute respiratory distress, and the EHR showed that R70 was receiving oxygen. The MDS indicated that R70 was receiving oxygen and had a BIMS score of 07, showing little to no cognitive impairment. The physician order dated 02/03/2025 directed oxygen at 4 LPM via nasal cannula every day and night shift for emphysema and asthma, and another order directed tubing and humidifier changes every day shift every Monday. The care plan also identified oxygen therapy as a focus area and directed staff to administer oxygen and monitor O2 saturation as ordered. Observations showed that R70 was receiving oxygen from a concentrator by nasal cannula at 3.5 LPM on 02/20/2026, instead of the ordered 4 LPM, and there was no humidifier bottle attached to the concentrator. On 02/21/2026, R70 was observed receiving oxygen at 4 LPM, but again without a humidifier bottle attached and in use. An LPN confirmed that the oxygen was at the correct rate during the later observation but acknowledged that the humidifier bottle was not attached and in use as ordered. The DON and Administrator confirmed that staff were expected to ensure the resident received oxygen at the correct flow rate and with a humidifier bottle according to physician orders.
Failure to Check Vital Signs Before Metoprolol Administration
Penalty
Summary
The facility failed to follow acceptable standards of practice when administering metoprolol to one resident with hypertension and moderate cognitive impairment. The resident was readmitted with a diagnosis that included hypertension, and the physician’s order was for metoprolol tartrate 50 mg by mouth twice daily. The comprehensive care plan revised 09/23/2025 did not include a written care plan addressing hypertension and/or associated medications. During medication administration observation on 02/21/2026 at 8:50 AM, an LPN administered metoprolol 50 mg to the resident without checking a pulse or blood pressure beforehand. The LPN stated there were no ordered parameters and that metoprolol should not be given if the resident’s heart rate was less than 60 bpm. Record review showed the resident had multiple heart rate readings below 60 bpm on several dates in February and January 2026. The ADON and DON stated nurses should call the doctor for parameters on medications such as metoprolol, and the pharmacist stated the resident should be monitored for drops in blood pressure and heart rate when receiving metoprolol.
Glucose Test Strips Found Without Open Dates
Penalty
Summary
Drugs and biologicals used in the facility were not labeled in accordance with accepted professional principles when two bottles of glucose test strips in two medication carts were found without open dates. During observation and interview on 02/21/2026, one bottle of blood sugar test strips in medication cart 1 on the [NAME] Wing had no open date, and an LPN present during the review confirmed it. A second observation the same day in medication cart 2 on the [NAME] Wing found another bottle of blood sugar test strips with no open date, and the LPN present also confirmed it. Record review showed the facility’s Checklist for Blood Sugar documented that blood glucose monitoring solution/strips are dated and expire 3 months after first use. The facility requested a policy for blood sugar strips, but no policy was provided. During interview, the ADON stated the opening date should be placed on glucometer strip bottles when first opened because nurses would not know when the days are up. The DON stated it was her expectation that open dates be placed on glucometer strip bottles upon opening and that, without an open date, the strips may not be effective within the required time period and residents may have inaccurate blood sugar readings.
Deficient Food Storage and Labeling Practices
Penalty
Summary
The facility failed to ensure proper labeling and storage of food items, as well as the timely disposal of expired food, which could potentially affect 85 residents who receive food orally. Observations revealed multiple instances of food items in the walk-in cooler, freezer, and pantry that were not labeled with expiration dates, including cheddar and Swiss cheese slices, turkey burgers, milkshakes, and various opened bags of food such as beef patties and French fries. Additionally, several food items were found to be improperly sealed or stored, such as an opened jug of barbeque sauce that was not refrigerated and expired items like prune juice and graham crackers in the resident pantry. Interviews with facility staff, including the Food and Nutrition Manager (FNM), Licensed Practical Nurse (LPN), and the Administrator, highlighted a lack of oversight and responsibility for checking and discarding expired food items. The FNM expressed an expectation for kitchen staff to work as a team to manage food labeling and disposal, but admitted to not being responsible for checking resident pantries. The LPN on the [NAME] Wing acknowledged not checking for expired items beyond juices, and the Administrator stated that all food should be labeled and checked daily, with unit managers overseeing the resident pantries. However, the absence of a unit secretary responsible for pantry checks contributed to the oversight.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to provide a resident or their representative with written information regarding their rights to accept or refuse medical or surgical treatment, as well as information about advance directives. This deficiency was identified for one of the seven sampled residents, who had medical diagnoses including anoxic brain damage, tachycardia, and protein calorie malnutrition. The resident was on hospice care with a Do Not Resuscitate (DNR) order, and the care plan indicated a need to complete or update the advance directives document. Interviews with facility staff, including the Administrator in training and the Social Service Director, revealed that the process for providing advance directive information involved giving the document to residents or their families during the admission conference. However, in the case of the resident in question, there was no indication that the advance directive form was completed or signed by the resident or their representative. The facility's policy and admission agreement form included sections for acknowledging the execution of an advance directive, but these were not marked for the resident, indicating a lapse in ensuring the resident's or representative's informed decision-making capacity.
Failure to Submit PASRR Level II for Resident with Mental Health Diagnosis
Penalty
Summary
The facility failed to submit a Preadmission Screening and Resident Review (PASRR) Level II for a resident with a mental health diagnosis, which was necessary for ensuring the resident received appropriate services and care. The resident, identified as R82, had a primary diagnosis of secondary malignant neoplasm of bone, along with vascular dementia, anxiety disorder, and psychosis not due to a substance or known physiological condition. Despite these diagnoses, the facility did not have a policy on PASRR, and the necessary Level II screening was not submitted in a timely manner. Interviews with facility staff, including the Social Service Director (SSD) and the Medical Records Coordinator, revealed a lack of clarity and communication regarding the PASRR process. The SSD indicated that clinical information was typically entered into the Georgia Medicaid Management Information System (GAMMIS) by the hospital, but if not, the facility would enter it. The SSD was in the process of submitting a Level II for R82 on the day of the interview, indicating a delay in the process. The Medical Records Coordinator noted that for new admissions, a DMA-6 form was completed, and if a resident was to stay longer than 30 days, the hospital would enter the necessary information into the Georgia portal. However, there was confusion about who was responsible for submitting the Level II, especially for residents with mental health diagnoses.
Failure to Implement and Develop Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement care plans for three residents, leading to deficiencies in monitoring and recording meal intake and oxygen use. For one resident with severe cognitive impairment and a risk for weight loss, the care plan required recording meal intake percentages and offering food replacements for less than 25% consumption. However, documentation was missing for numerous days over a three-month period, indicating a failure to implement the care plan effectively. Another resident, who had little to no cognitive impairment and was at risk for nutritional deficits, also had a care plan that required recording meal intake percentages. Despite consuming between 51-100% of meals, there were several days without documentation of intake percentages. Interviews with staff confirmed that CNAs were responsible for documenting meal consumption in the electronic medical records system daily, but this was not consistently done. A third resident with moderate cognitive impairment and a diagnosis of COPD was using oxygen, but there was no care plan developed for oxygen use. Observations revealed the resident's oxygen was set at a higher level than ordered by the physician. The MDS Coordinator admitted to not creating a detailed care plan for oxygen use, and the DON expected staff to follow physician orders precisely. This lack of a specific care plan for oxygen use contributed to the deficiency.
Failure to Maintain Working Door Alarm Leads to Resident Elopement
Penalty
Summary
The facility failed to ensure a working door alarm to prevent the elopement of a resident housed on a COVID unit. The resident, who had severe cognitive impairment and a history of wandering, was moved from a locked dementia unit to a COVID unit. Despite the facility's policy on accident and hazard prevention, the door alarm on the COVID unit was inoperable, allowing the resident to bypass two doors and exit the facility. The resident was later found outside by neighbors and returned by the police. Interviews with facility staff, including the Director of Nursing, Assistant Director of Nursing, Maintenance Director, and Administrator, revealed that the resident was not on one-on-one monitoring, and the alarm system failure was acknowledged. The resident was last seen in her room before being found outside, indicating a lapse in supervision and safety measures. The facility's attempt to manage the situation during the COVID outbreak led to the resident being moved, but the necessary safety precautions were not adequately maintained, resulting in the resident's elopement.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to ensure that oxygen was administered as ordered by the physician for a resident receiving oxygen therapy. The resident, who had a history of chronic obstructive pulmonary disease, emphysema, chronic bronchitis, and atherosclerotic heart disease, was observed with oxygen set at 2.5 liters per minute, contrary to the physician's order of 2 liters per minute. This discrepancy was noted during multiple observations over two days. The facility's policy required that any changes in oxygen flow made by the respiratory therapist or nursing staff be communicated to the physician within 24 hours to obtain a new order, which was not adhered to in this case. Interviews with staff revealed a lack of adherence to the physician's orders and the facility's policy. An LPN confirmed the oxygen setting and indicated that the respiratory therapist determined the level unless changed by the physician. The MDS Coordinator admitted to not having completed a detailed care plan for the resident's oxygen therapy. The DON expressed that staff were expected to follow physician orders precisely and that care plans should be implemented according to diagnoses, which was not done in this instance.
Failure to Follow Pureed Food Preparation Procedures
Penalty
Summary
The facility failed to prepare pureed food according to established procedures, which compromised the nutritive value, flavor, and appearance of the food. Specifically, the facility did not use a recipe when preparing pureed food for residents on a pureed diet. Observations revealed that a staff member, [NAME] BB, was preparing pureed spaghetti without referring to a formal recipe. Instead, she relied on her experience and used a ladle to measure thickened powder, rather than following precise measurements. This practice was intended to serve 10 residents, with the desired consistency being nectar thick. Interviews with the Food and Nutrition Manager (FNM) and the Administrator highlighted a lack of adherence to the facility's policy. The FNM was aware that the cook was not following the recipe but mentioned that recipes could be printed for reference. The Administrator expected dietary staff to be trained and to follow recipes for pureed diets. The deficiency had the potential to affect 13 residents who were ordered a pureed diet, as the preparation did not adhere to the facility's policy to ensure the best possible product without compromising flavor and texture.
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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