Pruitthealth - Decatur
Inspection history, citations, penalties and survey trends for this long-term care facility in Decatur, Georgia.
- Location
- 3200 Panthersville Road, Decatur, Georgia 30034
- CMS Provider Number
- 115647
- Inspections on file
- 20
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Pruitthealth - Decatur during CMS and state inspections, most recent first.
A Laundry Aide delivered clothes on a partially covered cart instead of the enclosed transport cart, and a cell phone was found in a clean linen cart. Staff confirmed both practices were not acceptable and identified cross contamination and infection control concerns.
Hazardous Chemical Left Accessible in Hallway: A can of cleanser deodorizing powder was observed on a hallway handrail outside a resident's room with no staff or housekeeping cart nearby. An LPN confirmed the chemical should not have been there, and the DHS and Administrator stated chemicals should be kept in a locked area because leaving them in the hallway is unsafe.
A resident reported that after requesting evening medications, a nurse left the room and was overheard saying, “I’m not going back in there. I may have to slap someone.” The resident called a family member, who came to the facility, questioned why police had not been notified, and later filed a police report. The resident also filed a formal grievance documenting the nurse’s statement. Despite a written policy requiring that all real or perceived abuse allegations, including verbal threats, be reported to the SSA within two hours and investigated, the facility treated the incident as a customer service issue, reassigned the nurse, and did not report the allegation to the SSA or conduct an abuse investigation, as confirmed by staff interviews.
A resident with an indwelling suprapubic catheter related to neurogenic bladder, BPH, and urinary retention had a care plan that included multiple catheter-related interventions but did not include a physician’s order to irrigate the catheter with normal saline every shift. Facility policy required the comprehensive care plan to describe all services to be furnished, and the omission occurred despite established processes for the MDS Coordinator and IDT to communicate order changes and for nursing leadership to ensure timely care plan updates.
A resident with a suprapubic catheter had the urinary bag visible from the hallway without a privacy cover, and an attempted cover was hanging on the bed frame instead of covering the bag. The resident had multiple diagnoses including hemiplegia, DM2, epilepsy, receptive-expressive language disorder, and dysphagia. Staff, including a CNA and the DON, confirmed the bag was not properly covered, and the facility’s resident rights and catheter policies did not address covering the bag.
A resident with bipolar disorder, MDD, anxiety disorder, PTSD, and schizophrenia was admitted with a Level I PASARR, but the record showed no Level II PASARR evaluation. The MDS indicated the resident had not been evaluated, and a PASRR Level II referral was cancelled because the facility did not provide the medication list needed to complete the assessment. The SSD, DON, and Administrator stated they assumed the screening had been completed or was handled by others.
A resident with dementia and total incontinence and another resident with MS and bowel/bladder incontinence did not receive timely incontinent care, with staff confirming wet briefs, urine odor, and delayed changes despite care plan directions for prompt care after each episode. A separate resident with a suprapubic catheter had catheter irrigation supplies that were not sterile and were not set up per the ordered procedure; an LPN confirmed the items used for irrigation and showed a syringe that would not fit the catheter, while the DON stated catheter irrigation was expected to be sterile.
Unlocked and Unattended Medication Cart: Surveyors observed one first-floor medication cart left unlocked and unattended, with several rolls of resident medication on top. The LPN confirmed she left the cart while going to the bathroom and said her support staff was on break; the DON and Administrator confirmed the observation. Facility policy required medication carts to be locked or attended by authorized personnel.
The facility failed to dispose of expired food items in accordance with its policies, as observed during an inspection. Expired items were found in the dry storage pantry, walk-in freezer, and on kitchen shelves, including water bottles, donuts, and various seasonings. Interviews with the DM and DON confirmed the presence of expired items, which should have been removed to prevent potential illness among residents.
A long-term care facility failed to implement proper infection control measures, including Enhanced Barrier Precautions (EBP) for a resident with a stage 2 pressure ulcer and adequate hand hygiene by staff. An LPN did not sanitize hands between assisting residents, and the resident with the wound was not placed on EBP, contrary to facility policy. Staff confirmed these practices could lead to cross-contamination and infections.
The facility failed to ensure that the POLST and medical records accurately reflected residents' code status choices. One resident's POLST indicated full code, while physician orders stated DNR, and the face sheet had conflicting information. Another resident's POLST showed AND and DNR, but physician orders listed full code. The SSD and DON confirmed these inconsistencies, and an audit was underway to correct the records.
The facility failed to maintain cleanliness in two resident rooms, compromising resident safety. In one room, the PTAC unit had visible debris, including a dead bug, due to inconsistent cleaning schedules. In another room, a dark brown substance was found on bathroom surfaces, indicating inadequate cleaning and disinfection procedures. Staff interviews revealed a lack of clarity in cleaning responsibilities, increasing infection risk.
A facility failed to submit a PASARR Level II for a resident after a new mental illness diagnosis was added. The resident had diagnoses including bipolar disorder, major depressive disorder, anxiety disorder, and PTSD. The Social Service Director confirmed the oversight, acknowledging the responsibility to refer for PASARR Level II evaluation when a new mental disorder is identified.
Clean Linen and Laundry Cart Cross-Contamination
Penalty
Summary
The facility failed to protect clean linen from cross-contamination when a Laundry Aide delivered clothes on a partially covered laundry cart to the first floor. During observation, the Laundry Aide confirmed she was using the laundry sorting cart instead of the enclosed transportation cart because the enclosed cart was difficult for her to push due to back concerns, and she acknowledged that the cart should have been covered. The Environment Manager later stated that laundry was expected to be delivered in a timely manner, properly covered, and without additional items on the cart, and confirmed that uncovered transport was not his expectation because it created an infection control issue and items were not isolated. The facility also had a cell phone placed in a clean linen cart. A CNA confirmed the phone was hers and stated it should not have been in the linen cart, identifying cross contamination as the consequence of personal items being placed there. The Director of Health Services and the Administrator stated that personal items left on clean linen carts were not acceptable and that nothing personal should be in the clean linen cart because of the potential negative impact on infection control.
Hazardous Chemical Left Accessible in Hallway
Penalty
Summary
The facility failed to store potentially hazardous chemicals so they were not accessible to cognitively impaired residents. During an observation on 03/04/2026 at 5:28 AM, a 21-ounce can of name brand cleanser deodorizing powder was found placed on a handrail in the second-floor hallway by a resident's room, with no staff or housekeeping cart in sight. An LPN confirmed at 5:31 AM that the can was in the hallway and stated it should not have been there, adding that she was not sure why it was left there. Later, the Director of Health Services and the Administrator stated that chemicals should not be left in the hallway and should be kept in a locked area for the health and safety of staff and residents.
Failure to Report and Investigate Allegation of Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of verbal abuse to the State Survey Agency (SSA) and to conduct an abuse investigation in accordance with its own policy and regulatory requirements. The facility’s policy on reporting patient abuse, neglect, exploitation, mistreatment, and misappropriation of property required the Administrator or designee to notify the appropriate state agencies, the attending physician, and the patient’s representative of any allegation of abuse, including verbal threats, within two hours of the allegation. The policy also required that an investigation be initiated into the allegation. A resident reported that, after requesting evening medications, she overheard a nurse leaving her room and stating, “I’m not going back in there. I may have to slap someone.” The resident subsequently telephoned her family member to report this statement. The resident’s family member went to the facility, questioned why police had not been notified, and reported that the nurse who initially received his concern did not act and stated he was getting ready to go home. The family member filed a police report that same evening. The resident later filed a formal grievance documenting the nurse’s statement, and the facility categorized the occurrence as a customer service matter, removed the nurse from the resident’s assignment, and planned staff inservices on good customer service. The facility did not report the allegation to the SSA and did not complete an abuse investigation related to the verbal threat. Staff interviews, including with a CNA, the Social Services Director, and the Administrator, confirmed that real or perceived allegations of abuse, including verbal threats, were understood to be reportable and to require immediate reporting and investigation, but this did not occur for this resident’s allegation.
Failure to Add Ordered Catheter Irrigation to Resident Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to include physician-ordered suprapubic catheter irrigation in a resident’s comprehensive care plan. The facility’s care plan policy, revised 10/21/2025, requires that the comprehensive care plan describe the services to be furnished to attain or maintain the resident’s highest practicable well-being. Review of the resident’s care plan dated 12/10/2025 showed a problem of an indwelling catheter related to neurogenic bladder, BPH, and urinary retention, with interventions such as changing the catheter at the urologist’s office per spouse preference, administering cranberry supplement for UTI prophylaxis as ordered, keeping catheter tubing free of kinks, maintaining the drainage bag below bladder level, preventing tension on the urinary meatus, and providing catheter care per policy. However, there was no mention of irrigating the urinary catheter. Record review showed a physician’s order for the resident to have the suprapubic catheter irrigated with 50 cc of normal saline every shift, which was not reflected in the care plan. In interviews, the MDS Coordinator stated she communicated with the IDT in morning meetings about changes to orders or residents’ status and indicated she should have been informed of the urinary catheter irrigation order so she or a unit nurse could add it to the care plan. The DON stated that expectations were for the Charge Nurse, Unit Manager, or MDS Coordinator to make care plan changes as soon as they were ordered. The Administrator reported that the MDS department had stated in a morning meeting that they were caught up with MDSs and care plans, but that this was not accurate.
Visible Urinary Catheter Bag Without Privacy Cover
Penalty
Summary
The facility failed to provide dignity to one resident with an indwelling urinary catheter because the catheter bag was visible from the hallway and was not covered with a privacy cover. The facility’s resident rights policy and indwelling catheter policy did not mention covering the urinary bag. The resident, R88, was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, type 2 diabetes mellitus, epilepsy, hyperlipidemia, contracture of the left hand, receptive-expressive language disorder, and dysphagia. The resident’s CAA identified problems with communication, ADLs, an indwelling catheter, dental care, and a pressure ulcer, and the care plan included an indwelling catheter problem and prophylactic ABT. R88 had a suprapubic catheter insertion and physician orders for catheter care every shift and a 16Fr catheter with a 10cc bulb. During observations, the urinary catheter bag was seen visible from the hall without a privacy cover, and later an attempt to cover it was observed, but the cover was hanging on the bed frame and did not cover the bag. A CNA confirmed the bag was not properly covered. The DON stated the foley bag came from the hospital without a cover and that a cover had to be put on it, and the Administrator stated resident rights always came first.
Failure to Complete Level II PASARR for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a Level II PASARR was completed for a resident with multiple mental health diagnoses, including bipolar disorder, major depressive disorder, anxiety disorder, PTSD, and schizophrenia. Record review showed the resident was admitted with a Level I PASARR, and the MDS indicated he had not been evaluated for a Level II PASARR. The care plan addressed psychosocial wellbeing and difficulty expressing self related to a history of CVA, but the record also included a Georgia PASRR Level II referral cancellation notice stating the referral was cancelled because the facility failed to provide the medication list needed to complete the assessment. During interviews, the Social Services Director stated that, based on the resident’s diagnoses, a Level II PASARR should have been performed within 30 days of admission. She also stated the resident had been admitted before she was onboarded and that the resident was not included in a PASARR audit she had completed. The DON and Administrator stated they assumed the resident’s PASARR II had been performed by the SSD, and the DON confirmed the resident qualified for screening but was unsure why he was screened. The DON also stated the assessment was carried out at admission, consent was obtained from the family, and a mental health provider was contacted.
Delayed Incontinence Care and Improper Catheter Irrigation
Penalty
Summary
Timely incontinence care was not provided for two residents who were documented as always incontinent of bowel and bladder. One resident had diagnoses including Alzheimer’s disease, dementia, chronic kidney disease, and palliative care, and was dependent for ADLs. The resident’s care plan directed staff to provide incontinent care after each episode and keep the resident clean and dry. During observations, the resident’s room smelled of urine on multiple occasions, and staff confirmed the resident smelled of urine and had a wet brief. One CNA stated the resident had last been changed at 7:00 AM while also reporting responsibility for 14 residents. Another CNA stated the resident had last been changed between 7:30 AM and 8:00 AM and did not change the resident after the interview. A third CNA stated she changed residents every two hours but confirmed the resident smelled of urine and had a wet brief, stating the resident had last been changed around 3:00 AM. A second resident with multiple sclerosis, urinary retention, and bowel and bladder incontinence was cognitively intact and required substantial to maximal assistance for toileting and hygiene. The resident’s care plan directed staff to offer peri care before leaving the room and provide incontinent care after each episode. The resident filed grievances stating that on two occasions the resident was not changed from 11:00 PM to 7:00 AM and was not changed until 9:00 AM. A CNA statement confirmed the resident pressed the call light at 11:20 PM requesting to be changed, but staff told the resident they were waiting for other CNAs to arrive before assisting. The statement also documented that rounds began at 1:00 AM on the other end of the hall and did not start with the resident’s need. During an interview and observation, the resident stated the resident had not been changed since 3:00 AM and would probably not be changed until 9:00 AM or 9:30 AM. Appropriate catheter irrigation and sterile catheter care were not provided for a resident with a suprapubic urinary catheter, neurogenic bladder, diabetes, multiple sclerosis, chronic pain, and bowel incontinence. The resident’s physician ordered irrigation of the suprapubic catheter with 50 cc normal saline every shift, and the care plan directed catheter care per policy. In the resident’s room, surveyors observed two catheter-tip syringes stored in bags labeled as tube feeding syringes, along with opened bottles of normal saline on the nightstand; the syringes were not sterile and there was no date showing when the saline or syringes had been opened. The resident stated these items were used to irrigate the catheter every shift. An LPN confirmed the items were used for catheter irrigation and stated that was all the facility had available. The LPN then showed a 10 mL prefilled sterile syringe of sterile normal saline used to flush IV catheters, stating it was what she used to flush the resident’s catheter, although the syringe had a Luer-Lok tip and would not fit a catheter. The DON stated catheter irrigation was expected to be done in a sterile fashion.
Unlocked and Unattended Medication Cart
Penalty
Summary
The facility failed to ensure that one of two medication carts on the first floor was locked and attended. During a tour on 03/04/2026 at 5:05 am, surveyors observed the door to a medication cart on the first floor left unlocked and not being directly monitored by authorized personnel. Several rolls of unidentifiable resident medication were found on top of the cart. The report states the cart was unattended at a time when wandering residents were on the floor. Review of the facility policy titled Medication Storage in Healthcare Centers stated that medications and biologicals are to be stored safely and securely, and that medication rooms, carts, and medication supplies are to be locked or attended by persons with authorized access. In interview, the LPN confirmed the cart was hers and said she had rushed to the bathroom due to an urgent need while her support staff was on break. She also stated she could have completed the task of putting away the medication or placed it in the cart until her return. The DON and Administrator confirmed the observation of the unlocked and unattended medication cart, and the DON identified the medication on top of the cart as pizza roll, which was used for blood pressure, cholesterol, and other resident-specific purposes.
Expired Food Items Found in Facility Kitchen
Penalty
Summary
The facility failed to adhere to its policies on food safety, specifically regarding the disposal of expired food items. During an inspection, surveyors observed expired items in the dry storage pantry, including four one-gallon bottles of water and 24 bottles of distilled water. Additionally, the walk-in freezer contained four packs of expired variety pack donuts. Further inspection revealed several expired seasoning bottles on a shelved area in the kitchen, including ground thyme, sesame seed, sriracha seasoning, poultry seasoning, paprika seasoning, crushed red pepper seasoning, and whole celery seed. Interviews with the Dietary Manager (DM) and the Director of Nursing (DON) confirmed the presence of expired food items in the kitchen. The DM acknowledged that expired food items should not be present in the kitchen and emphasized the importance of removing them before they expire to prevent potential illness among residents. The DON stated that audits should be conducted to ensure expired food items are removed and disposed of, as their presence could lead to residents becoming sick from consuming expired products. The deficiency had the potential to affect 124 residents receiving food from the kitchen, with the facility's census being 130.
Inadequate Infection Control Measures in LTC Facility
Penalty
Summary
The facility failed to implement proper infection prevention and control measures, as evidenced by the lack of Enhanced Barrier Precautions (EBP) for a resident with a wound and inadequate hand hygiene practices by staff. Specifically, a Licensed Practical Nurse (LPN) did not sanitize her hands after pushing a resident's wheelchair and before assisting another resident with their meal. This was confirmed through observations and staff interviews, where it was acknowledged that such practices could lead to cross-contamination and the spread of infections among residents. Additionally, the facility did not place a resident with a stage 2 pressure ulcer on EBP, despite the facility's policy requiring such precautions for residents with wounds. The resident, who had severely impaired cognition, was receiving treatment for the pressure ulcer but was not on EBP, as confirmed by multiple staff members, including the Wound Care Nurse and the Assistant Director of Nursing. The staff indicated that the decision to place residents on EBP was at the discretion of the facility, which led to the omission of necessary precautions for the resident. The failure to adhere to the facility's infection control policies, both in terms of hand hygiene and EBP, was acknowledged by various staff members, including the Director of Nursing and the Clinical Competency Coordinator. These deficiencies had the potential to cause infections for the resident with the wound and other residents in the facility, as the lack of proper precautions could facilitate the transmission of germs.
Discrepancies in POLST and Code Status Documentation
Penalty
Summary
The facility failed to ensure that the Physician Orders for Life Sustaining Treatment (POLST) and other medical records accurately reflected the residents' choices regarding their code status. For one resident, there was a discrepancy between the POLST, which indicated a full code status, and the physician's orders, which stated Do Not Resuscitate (DNR). Additionally, the resident's face sheet contained conflicting information, listing both full code and Do Not Intubate (DNI) statuses. Interviews with the Social Services Director (SSD) and the Director of Nursing (DON) confirmed these inconsistencies and acknowledged that the advance directive was not reconciled with the physician orders. Another resident's records also showed inconsistencies, with the POLST indicating Allow Natural Death (AND) and Do Not Attempt Resuscitation, while the physician's orders listed a full code status. The face sheet for this resident showed a DNR status. The SSD revealed that nurses were responsible for entering orders upon admission and suggested that the discrepancy might have occurred during a readmission from the hospital. The SSD was conducting an audit to ensure that the system accurately reflected the residents' wishes.
Facility Fails to Maintain Cleanliness in Resident Rooms
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in two resident rooms, compromising the health and safety of the residents. In one room, the Packaged Terminal Air Conditioner (PTAC) unit was found with visible debris, including a dead bug, indicating a lack of regular maintenance and cleaning. The facility's policy required air filters to be cleaned or replaced every three months, and the manufacturer's guidelines recommended a thorough cleaning of the unit annually. However, interviews with the Maintenance Director and other staff revealed inconsistencies in the cleaning schedule, with PTAC units generally cleaned once a year and filters cleaned monthly. The Administrator acknowledged the expectation to follow the manufacturer's specifications, but the PTAC units had not been cleaned recently, posing a risk of airborne illness if debris were to be blown into the room. In another room, the bathroom was observed with a dark brown substance smeared on the inside door handle, handrails, and door jams. Despite some cleaning efforts, the inner sides and door jams remained soiled. Interviews with housekeeping and nursing staff indicated a lack of clarity and coordination in responsibilities for cleaning bodily fluids. The Housekeeping Aide and Certified Nursing Assistants (CNAs) were expected to clean up body fluids, with housekeeping following up to disinfect the areas. However, the presence of the brown substance suggested that these procedures were not effectively implemented, increasing the risk of infection for the residents.
Failure to Complete PASARR Level II for Resident with New Mental Illness Diagnosis
Penalty
Summary
The facility failed to submit a Preadmission Screening and Resident Review (PASARR) Level II for a resident after a new mental illness diagnosis was added. The resident, identified as R10, was admitted with diagnoses including bipolar disorder, major depressive disorder, anxiety disorder, and PTSD. Despite these qualifying diagnoses, the facility did not complete a PASARR Level II, which is necessary to ensure the resident receives the appropriate level of care and services. The deficiency was identified through a review of R10's electronic medical records and an interview with the Social Service Director (SSD). The SSD confirmed that it was her responsibility to refer residents for a PASARR Level II evaluation when a new mental disorder, intellectual disability, or related condition was identified. However, she acknowledged that this referral was not made for R10, despite the resident's current diagnoses requiring it. This oversight had the potential to affect the care and services provided to the resident.
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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