Pine View Nursing And Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Sylvania, Georgia.
- Location
- 411 Pine Street, Sylvania, Georgia 30467
- CMS Provider Number
- 115544
- Inspections on file
- 20
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Pine View Nursing And Rehab Center during CMS and state inspections, most recent first.
Improper Puree Food Preparation: The facility failed to properly prepare pureed meals for eight residents on a pureed diet. One DA loaded food into a processor without measuring, did not use liquids or a recipe, and did not check the consistency before serving. Another DA prepared sweet potatoes without following the recipe or proper measurements, used broth instead of the documented ingredients, and stated she had not been formally trained. The DM confirmed staff were not using the puree recipe book and were being verbally instructed on ingredients.
Food storage and sanitation practices were not maintained in the kitchen. Surveyors observed ice buildup and icicles in the freezer, frozen foods stored without date labels, and an opened loaf of bread, molded cheese, an opened box of pancakes, and a staff member's personal medications in the refrigerator. Staff also used bleach at the 3-comp sink, prewashed dishes before the dishwasher, hand-dried items with a dish towel, and confirmed the dishwasher temperature gauge and chemical strips were not functioning properly.
The facility failed to maintain an effective QAPI program and could not produce documentation for review, including meeting attendance records and the QAPI policy. The Administrator stated the facility does not maintain QAPI documentation, the QAPI program is not effective, and there is no tracking or trending of data for trends; most issues are addressed during the morning clinical meeting. This deficient practice affected 109 residents.
Medication administration errors exceeded the allowed rate after an LPN gave multiple ordered G-tube medications by mouth to a resident and administered Seroquel at half the ordered dose. The resident’s orders and MAR matched, but the nurse did not follow the prescribed route or dosage, and facility leadership stated nurses were expected to follow physician orders and the rights of medication administration.
A resident with a G-tube, dysphagia, and multiple chronic conditions was ordered several medications to be administered via the G-tube. During observation, an LPN gave all of the medications by mouth instead of by the ordered route and confirmed the orders called for G-tube administration; an APRN later verified that the resident should have received the medications via the G-tube.
The facility failed to ensure proper infection control during meal service, as CNAs did not sanitize their hands between resident contacts on two halls. Additionally, the facility lacked an effective water management program to prevent Legionella growth, as the previous Maintenance Director took all related documentation upon leaving. The facility was in the process of developing a new program.
The facility failed to maintain a safe and sanitary environment, with issues such as patched walls, stained ceiling tiles, and foul odors noted in multiple areas. The D Hall had a persistent urine odor, linked to bins containing soiled linens and incontinence pads. Staff confirmed these conditions, and the Administrator acknowledged the need for an odor-free environment.
A resident was found with unauthorized vitamins at their bedside, despite facility policy requiring physician authorization for bedside medication storage. Staff interviews confirmed that medications are not allowed at the bedside without specific authorization, and the vitamins were subsequently removed by an LPN.
A facility failed to provide written bed hold notices for a resident who was hospitalized twice, as required by their policy. Despite the policy being part of the admission packet, the Business Office Manager confirmed that no bed hold notice was issued during the resident's hospital transfers, leading to a deficiency.
A facility failed to accurately code the MDS assessment for a resident with mental health diagnoses, including schizophrenia and bipolar disorder. The resident's MDS incorrectly stated that a Level II PASRR evaluation had not been conducted, despite it being completed. The MDS Coordinator confirmed the error, and RN GG, responsible for signing off on the MDS, did not check for accuracy. The Administrator acknowledged the lack of a specific MDS policy, relying instead on RAI guidelines.
Two residents in the facility did not receive adequate ADL care. One resident with severe cognitive impairment had long, dirty fingernails, while another resident, dependent on assistance for ADLs, reported not receiving help with brushing teeth for over two weeks. CNAs confirmed the lack of care, and the DON stated that nail and oral care should be part of daily ADL care.
The facility failed to document controlled medication shift counts with nurse signatures on the D Hall Medication Cart, missing 28 signatures out of 112 opportunities. This deficiency was identified through observations and staff interviews, revealing a lack of adherence to the facility's policy on controlled substances. The Nursing Supervisor and DON emphasized the importance of signing the controlled substance sheet at each shift change to ensure medication availability.
Expired medications were found in a medication storage room, including 14 blister packs and bottles of vitamin D, despite facility policy requiring their removal. An LPN and Nursing Supervisor confirmed the oversight, and the DON stated that expired medications should be removed to prevent resident exposure.
Improper Puree Food Preparation
Penalty
Summary
The facility failed to properly prepare pureed food and ensure nutritive value for eight of eight residents receiving a pureed diet. The facility’s Nutrition Policy stated that pureed food should be a smooth, pudding-like texture and that pureed recipes are needed for each item requiring fluid and mechanical manipulation, using only nutritive fluids such as broth, gravy, juice, and milk. During observation of the puree process, Dietary Aide II loaded food into a processor without measuring, did not use liquids to dilute or liquify the food, did not follow a recipe, and did not assess the consistency before transferring it to a serving tray. In interview, the aide stated she was not aware she had to use a recipe and had not been trained on the proper technique for puree preparation. A second observation showed another Dietary Aide preparing sweet potatoes by placing seven scoops into a food processor, adding three scoops of broth, blending the mixture, tilting it back and forth, and pouring it into a serving tray. She stated she did not follow the recipe or use the proper measurements documented for the eight residents on a pureed diet, used liquid from the baked potatoes instead of milk, and was not formally trained on puree meal preparation. The puree recipe book reviewed by surveyors did not include a recipe recommendation for hamburger helper preparation, and the dietary manager stated staff were not using the puree recipe book while preparing meals and were instead being verbally instructed on what ingredients to use.
Food Storage and Dishwashing Sanitation Failures
Penalty
Summary
Food was not stored, prepared, and sanitized in accordance with professional standards in the kitchen serving 104 residents on oral diets. During the initial kitchen tour, surveyors observed a thick buildup of ice on the freezer floor with icicles hanging from boxes stored on the shelves. Several bags of frozen foods, including French fries, hamburger patties, mixed vegetables, and meats, were stored in a box on a shelf without an expiration date or opened/used-by date documented. In the refrigerator, an opened loaf of bread, a few slices of molded cheese, an opened box of pancakes, and a staff member's personal medications were observed together. Surveyors also observed the three-compartment sink with pots and pans being washed by staff using a bottle of bleach as sanitizer. The dishwasher was observed running while one staff member prewashed dishes, cups, and utensils and another hand-dried them with a dish towel. Staff interviews confirmed the dishwasher was not working correctly, the chemicals for the 3-compartment sink had been hooked up incorrectly, and the dishwasher temperature gauge was not registering while chemical testing strips did not give a reaction. The Dietary Manager stated staff had been hand washing dishes before placing them into the dishwasher and adding bleach to assist with sanitizing, and the Corporate Manager stated staff were instructed to continue using bleach and run another cycle until the repairman arrived.
Failure to Maintain QAPI Documentation and Program Oversight
Penalty
Summary
The facility failed to maintain an effective QAPI program that systematically identified, reviewed, developed, and implemented plans to correct quality deficiencies. Based on record review and staff interviews, the facility could not produce any documentation for review related to its QAPI program, including meeting attendance records, and the QAPI policy was also not produced. The Administrator stated on interview that the facility does not maintain QAPI documentation because it has not been documented as required, that the QAPI program is not effective, and that there is currently no tracking or trending of data for trends. She further stated that most issues are addressed during the morning clinical meeting. The deficient practice was identified as affecting 109 residents.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
Medication administration error rates were found to be 38.46% based on 26 observed opportunities with 10 errors, exceeding the facility policy requirement that medication errors remain below 5%. During observation of medication administration on the C Wing, an LPN administered multiple medications to one resident by mouth, including clopidogrel, divalproex sodium, lactobacillus, mirabegron, Actos, Seroquel, carvedilol, gabapentin, buspirone, and paroxetine. Review of the resident’s February 2026 physician orders showed these medications were ordered to be given via G-tube, and the MAR confirmed the orders were transcribed correctly. The observation and record review showed the medications were given by the wrong route. In addition, Seroquel was administered at 200 mg even though the order was for 400 mg. The LPN confirmed she gave the medications by mouth and stated the resident had been sneaking and eating and that the facility was trying to get the G-tube removed, but acknowledged she should have followed the orders because the resident could have aspirated. The ADON and Administrator stated that nurses were expected to follow physician orders and the rights of medication administration.
Medications Given by Mouth Instead of via G-Tube
Penalty
Summary
The facility failed to ensure that medications were administered according to physician orders for one resident with a G-tube. The resident was readmitted with diagnoses including COPD with acute exacerbation, hyperlipidemia, dysphagia, major depressive disorder, and altered mental status. The resident’s MDS showed a BIMS score of 15, indicating cognitive intactness, and the care plan identified the resident as NPO with tube feeding and aspiration precautions due to alteration in nutrition related to the G-tube and significant weight loss concerns. The physician orders directed multiple medications to be given via G-tube, including clopidogrel, divalproex, gabapentin, lactobacillus, mirabegron ER, paroxetine, and quetiapine, along with enteral feeding orders. During medication administration observation, an LPN gave all medications by mouth instead of via the G-tube. The LPN confirmed that the medication cards and physician orders were for G-tube administration and stated she gave the medications by mouth because the resident had been sneaking and eating and the facility was trying to get the resident cleared to remove the G-tube. An APRN later confirmed that the resident should have been receiving medications via the G-tube as ordered.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to ensure proper infection control practices during meal service on two of its halls, D Hall and E Hall. Observations revealed that CNAs did not sanitize their hands between resident contacts while serving meals. Specifically, CNA BB was seen not sanitizing her hands after leaving a resident's room and handling meal trays, while CNA HH also failed to sanitize her hands between serving meals to different residents. Both CNAs acknowledged their failure to follow hand hygiene protocols, citing forgetfulness and a desire to expedite meal service as reasons for their actions. The Director of Nursing confirmed that the expectation was for staff to sanitize their hands between resident contacts to prevent the spread of infections. Additionally, the facility did not have an effective water management program to prevent the growth of Legionella and other waterborne pathogens. The policy for Legionella surveillance was in place, but the facility could not provide a current water management program. The Maintenance Director and Environmental Services Director admitted that the previous Maintenance Director, who had left the facility, took all documentation related to the water management program. They were in the process of developing a new program, but at the time of the survey, no current program was in place, posing a risk of waterborne illnesses to residents.
Facility Environment Deficiencies
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment, as evidenced by observations and staff interviews. On three of five halls and one of two shower rooms, issues such as patched walls, stained ceiling tiles, missing floor tiles, scuffed walls, and foul odors were noted. Specifically, the A Hall had patched walls and stained ceiling tiles, while the C Hall shower room had missing floor tiles, scuffed walls, and a foul odor. These conditions were confirmed by the Administrator and Maintenance Director during observations. Additionally, the D Hall was reported to have an unpleasant odor, particularly of urine, which was strongest near specific rooms. Interviews with staff, including a CNA and the DON, confirmed the presence of the odor and identified bins containing soiled linens and incontinence pads as potential sources. The Environmental Services Lead noted that the bins, which contained incontinence trash and dirty laundry, were unique to the D Hall and were believed to contribute to the odor. The Administrator acknowledged the issue and expressed expectations for the facility to be odor-free.
Unauthorized Bedside Medication Storage
Penalty
Summary
The facility failed to ensure that unauthorized medications were not stored at the bedside for one of the sampled residents, identified as R10. The facility's policy on Bedside Medication Storage allows residents to self-administer medications only if there is a written order from the prescriber and the resident's self-administration skills have been assessed and deemed appropriate. However, R10's medical records did not contain any physician's order for self-administration of medications, nor was there a care plan area for self-administration. Despite this, a bottle of Gold Multi + Vita-Lea with Vitamin K was found on R10's bedside table, which R10 had been taking since before admission to the facility. R10 stated that the staff was aware of the vitamins. Interviews with facility staff, including a CNA, an LPN, the DON, and the Administrator, confirmed that medications are not allowed at the bedside unless specifically authorized by a physician. The LPN removed the unauthorized medications from R10's bedside, and the DON emphasized the risk of overdose if medications were left at the bedside. The Administrator reiterated that medications at the bedside posed a risk and that staff members were expected to remove any medications they observed to ensure resident safety.
Failure to Provide Bed Hold Notices for Hospitalized Resident
Penalty
Summary
The facility failed to provide written bed hold notices for a resident who was hospitalized, as required by their policy. The facility's undated Bed Hold Policy outlines the need for clear guidelines regarding payment sources to maintain or hold a resident's bed during hospital stays. However, during a review, it was found that the facility did not issue a bed hold notice for a resident who was transferred to a hospital on two separate occasions. The resident was initially transferred due to urgent medical needs and later due to abnormal breathing, with both instances documented in the Nurse's Notes. Interviews with the Business Office Manager and the Administrator confirmed that no bed hold notice was provided for the resident's hospital transfers. The Administrator mentioned that families are informed of the bed hold policy at admission, and it is included in the admission packet. However, the Business Office Manager admitted that she does not provide a bed hold policy when a resident is transferred to the hospital, which led to the deficiency identified in the report.
Inaccurate MDS Coding for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments were accurately coded to reflect the resident's status at the time of the assessment for one of the sampled residents, identified as R42. R42 was admitted with diagnoses including schizophrenia, bipolar disorder, major depressive disorder, and anxiety disorder. The Annual MDS for R42 incorrectly documented that the resident had not been evaluated by Level II PASRR, despite a PASRR Level II being completed on 9/21/2023. This discrepancy was confirmed by the MDS Coordinator during an interview. Further interviews revealed that Registered Nurse (RN) GG, who was responsible for signing off on the MDS assessments, did not verify the accuracy of the information. The Administrator acknowledged that RN GG's role was to confirm the completion of the MDS but expected the information to be accurate. The Administrator also confirmed that the facility did not have a specific MDS policy and relied on the Resident Assessment Instrument (RAI) guidelines. This lack of accurate coding on the MDS assessment had the potential to affect the assessment of R42's care needs.
Deficient ADL Care for Residents
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) care, specifically fingernail care and oral hygiene, for two residents. Resident 11, who has severe cognitive impairment and requires substantial assistance with ADLs, was observed with long fingernails and a dark substance underneath them. Despite the resident's preference for shorter nails, it was noted that they had not been cut for a month. A Certified Nurse Assistant (CNA) confirmed the condition of the nails and acknowledged the need for cleaning and trimming. The Director of Nursing (DON) stated that nail care is expected to be part of ADL care. Resident 2, who has no cognitive deficit but is dependent on assistance for all ADLs due to impairments in both upper extremities, was found to have a foul odor from the mouth, indicating a lack of oral hygiene. The resident reported not receiving assistance with brushing teeth for over two weeks, although mouthwash was provided. A CNA confirmed that while mouthwash was offered, assistance with brushing teeth was not provided. The DON emphasized the expectation for staff to assist with oral care daily and as needed.
Failure to Document Controlled Medication Shift Counts
Penalty
Summary
The facility failed to ensure that controlled medication shift counts were properly documented with nurse signatures on the D Hall Medication Cart. This deficiency was identified through observations, staff interviews, and a review of the facility's policy on Controlled Substance Prescriptions. The policy, revised in August 2020, mandates that medications classified as controlled substances by the DEA and state law must adhere to specific ordering, receipt, and record-keeping requirements. However, an observation on December 4, 2024, revealed that there were 28 missing signatures out of 112 opportunities for controlled-substance shift counts between September 29, 2024, and October 27, 2024. These missing signatures indicated a failure to document the shift counts for incoming and outgoing nurses, which is a critical step in ensuring the availability and accountability of controlled medications. Interviews with facility staff further highlighted the deficiency. The Nursing Supervisor expressed that her expectation was for nurses to count narcotics and document the count by signing the controlled substance sheet at each shift change. She noted that discrepancies in controlled medication counts could result in residents not receiving their medications if they were missing. Similarly, the Director of Nursing confirmed that controlled medications should be counted by nurses at shift change, and the controlled substance sheet should be signed by both the oncoming and off-going nurse to verify the accuracy of the count. The lack of adherence to these procedures posed a potential risk to the availability of residents' controlled medications.
Expired Medications Found in Storage Room
Penalty
Summary
The facility failed to ensure that expired medications were removed from one of its medication storage rooms, as observed during a survey. The facility's policy, revised in August 2020, mandates that all expired medications be removed from active supply and destroyed according to the policy. However, during an observation on December 4, 2024, 14 blister-pack medications with an expiration date of July 2024 were found on the counter in the Front Hall Medication Storage Room. Additionally, a bottle of vitamin D 250 mcg with an expiration date of October 2024 and a bottle of vitamin D 400 IUs with an expiration date of November 2024 were also found. These expired medications were verified by an LPN, who acknowledged that they should have been discarded. Interviews with facility staff further confirmed the oversight. A Nursing Supervisor confirmed the presence of the expired medications and stated that they should have been placed in a sealed bag and labeled for pharmacy pickup. The Director of Nursing expressed that the expectation was for nurses to remove expired medications from the medication room to prevent residents from potentially receiving them. The facility census at the time was 97 residents, indicating a significant risk of exposure to expired medications.
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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