Pruitthealth - Lithonia, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Lithonia, Georgia.
- Location
- 2816 Evans Mill Road, Lithonia, Georgia 30058
- CMS Provider Number
- 115473
- Inspections on file
- 22
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Pruitthealth - Lithonia, Llc during CMS and state inspections, most recent first.
Food safety practices were not followed in the kitchen when expired sour cream and milk were found in the walk-in cooler, expired milk was placed on meal trays and carts, and pork chops were observed submerged in water in the sink used for produce washing and meat thawing. A cook also reported manually adding sanitizer solution when the sanitizer machine was not working, without testing the concentration or measuring the volume, while dietary staff stated they had not received training on storage, labeling, and dating.
Dumpster Area Not Kept Clean and Closed: The facility failed to keep the outdoor dumpster and surrounding refuse area free of litter and in a sanitary condition. Surveyors observed two dumpsters, with one dumpster door left open and trash bags overflowing, along with debris including a box, gloves, straw remnants, and surgical masks around the area. The DM acknowledged the open dumpster and debris, the RD was unsure who was responsible for upkeep, and the Maintenance Director stated his department was responsible for dumpster maintenance.
Oxygen concentrator filter not maintained clean. A resident with chronic respiratory failure with hypoxia, dementia, shortness of breath, and dependence on supplemental oxygen had an oxygen concentrator filter observed with grey, fuzzy debris on multiple occasions. Facility policy required the external filter to be washed weekly and as needed, but staff interviews showed unclear responsibility for cleaning the filter, and the LPN, Maintenance Director, DON, and Administrator all observed visible dust or debris on the equipment.
An unlocked medication cart on the G Hall Corridor was observed unattended and out of direct sight of an RN for three to five minutes. RN DD confirmed the cart should have been locked, and CMA EE stated she stepped away briefly to get ice. The facility policy states medication supplies are to be stored securely and accessible only to authorized personnel.
Surveyors found that staff failed to maintain required cold holding temperatures for orange juice during breakfast meal service. Facility policy required the Dietary Manager or designee to ensure all potentially hazardous cold foods were held at or below 41°F, including keeping items on ice during tray line and limiting time on trays before service. During an observation, a cook measured three four-ounce containers of orange juice at temperatures above 51°F instead of 41°F or below. The cook acknowledged the correct standard, and the RD later confirmed that cold items should be kept on ice during tray line. This failure had the potential to affect most residents receiving an oral diet.
The facility failed to ensure proper food storage and sanitation, with expired and unlabeled food items found in storage areas. The ice machine showed signs of inadequate cleaning, and wet nesting of clean kitchenware was observed. The Dietary Manager and Registered Dietitian acknowledged these issues, indicating ongoing staff training and audits.
A facility failed to assess a resident with dementia for self-administration of medication, leaving pain-relieving ointments unsecured at the bedside. Another resident with intact cognition had medications left unattended in her room, contrary to facility policy. Staff interviews revealed a lack of awareness and adherence to procedures, posing risks of unauthorized access and medication interactions.
A resident with paranoid schizophrenia was not screened for PASRR level two, despite facility policy requiring such assessments for significant mental illnesses. The resident, taking anti-psychotropic and anti-depressant medications, was not referred for further evaluation as she exhibited no triggering behaviors. Staff interviews confirmed the oversight, potentially impacting the resident's access to appropriate care.
A CNA failed to clean a shared blood pressure cuff between uses on two residents, contrary to the facility's infection control policy. The CNA initially claimed to have cleaned the cuff but later admitted she had not, citing nervousness. The ADON confirmed the requirement for cleaning before and after each use.
The facility failed to resolve grievances related to lost personal items for three residents, as required by its grievance policy. Multiple clothing items went missing, and grievances were not documented or followed up in a timely manner. Interviews revealed a lack of clear procedures and accountability in handling grievances and lost items, leading to unresolved issues and dissatisfaction among residents and their families.
A resident with end-stage renal disease and bilateral amputations was not offered showers as per her care plan, despite being cognitively intact and expressing a preference for showers. The facility's records showed she was scheduled for showers twice a week, but she often received bed baths instead. Staff interviews revealed a lack of awareness of her preferences, and the DON confirmed she was not on the daily showers list, leading to inadequate hygiene care.
A facility failed to develop a person-centered care plan for a resident, a bilateral amputee with end-stage renal disease, regarding her bathing preferences. Despite being cognitively intact and expressing a preference for showers, the resident was not offered showers as per her care plan. Instead, she received bed or sponge baths, and staff were unaware of her preferences. The DON confirmed the resident was not on the Daily Showers list, leading to her receiving only one shower since admission.
A facility failed to maintain mechanical lifts in a state of readiness, affecting a resident with mobility and cognitive impairments. The resident, dependent on mechanical lifts for daily activities, was left waiting in discomfort due to an uncharged lift. Observations revealed multiple lifts not plugged in, and the DON acknowledged the issue, despite new lifts being purchased.
Expired Food and Improper Sanitizing Practices in Kitchen
Penalty
Summary
Food safety practices were not adequately upheld in the kitchen, as opened food products in the walk-in refrigerator were found unlabeled, undated, and not discarded when expired. During the initial tour, surveyors observed 19 one-ounce single packs of sour cream with an expiration date of 01/12/2026 and 10 half-pint cartons of milk with an expiration date of 03/15/2026 in the walk-in cooler/refrigerator. The facility’s policy required foods to be used before expiration, use-by, best-by, or sell-by dates and to be discarded if not used by those dates, and required food and beverage items to have identifying labels and received/opened dates as applicable. Surveyors also observed a large silver bowl containing meat, identified by the cook as pork chops, submerged in water in the sink designated for washing produce and thawing meat. During breakfast tray pass, expired milk was found on meal trays and carts, including on trays for two residents. One resident had a BIMS score of 14 with no cognitive impairment and a care plan noting risk for altered nutritional status with instructions to observe intake and provide the ordered diet. Another resident had a BIMS score of 12 with no cognitive impairment and a care plan noting a therapeutic diet with diet as ordered. In addition, the sanitizer machine for the three-compartment sink was not working, and a cook stated he manually poured sanitizer solution into the water without testing the sanitizer concentration or measuring the volume.
Dumpster Area Not Kept Clean and Closed
Penalty
Summary
The facility failed to ensure the outdoor garbage and refuse area was kept free of litter and maintained in a sanitary manner. The facility policy titled, Waste Disposal: Dietary Services, dated 10/20/2025, stated that dumpster lids, doors, and plugs should be kept closed at all times and that dumpster and surrounding areas should be kept clean and free of debris. During observation on 03/18/2026 at 11:58 AM, the Dietary Manager confirmed the presence of two dumpsters. The dumpster adjacent to the brick wall had its left door completely open and was overflowing with clear trash bags protruding from the opening. Surveyors also observed one compressed empty box, purple gloves, remnants of straws, and several white surgical face masks surrounding the dumpsters. The Dietary Manager acknowledged the trash and debris around the dumpster and confirmed the dumpster was open. A later observation on 03/18/2026 at 3:00 PM again showed the same dumpster mid-open with overflowing clear trash bags and purple gloves protruding onto the ground, along with the same debris around the dumpsters. The Registered Dietitian stated she was uncertain who was responsible for maintaining the dumpster, while the Maintenance Director stated his department was responsible for dumpster upkeep and noted that the night shift had been notified of their responsibilities.
Oxygen concentrator filter not maintained clean
Penalty
Summary
The facility failed to maintain respiratory equipment in a clean and sanitary manner for one resident receiving oxygen therapy. The resident was admitted with diagnoses including chronic respiratory failure with hypoxia, dementia, shortness of breath, and dependence on supplemental oxygen. The resident’s annual MDS documented that the resident was dependent on staff for all activities of daily living and received oxygen therapy and hospice services. Physician orders included oxygen at 3 liters per minute via nasal cannula continuously, with orders to change respiratory circuit/supplies weekly and monitor pulse oximetry as needed, and the care plan addressed oxygen use with interventions to administer oxygen as ordered and monitor for signs of hypoxia. Observations of the resident’s oxygen concentrator on three separate occasions showed the concentrator filter had grey, fuzzy debris present. Facility policy stated the large external black filter should be washed with soap and water once each week and as needed, and the exterior of concentrators should be cleaned weekly and between resident use. During interviews, the LPN, Maintenance Director, DON, and Administrator each observed the filter and noted visible dust or debris. The LPN stated the Maintenance Director was responsible for cleaning the filter, the Maintenance Director stated CNAs were expected to notify Maintenance when filters were dirty, the DON stated she was not aware of who was responsible for cleaning the filters or the process, and the Administrator stated she was unsure how often the filters were cleaned.
Unlocked Medication Cart Left Unattended
Penalty
Summary
Medications and biologicals were not stored securely on one of eight hallways when a medication cart on the G Hall Corridor was observed unlocked, unattended, and out of direct sight of a nurse. The cart remained unlocked and unattended for three to five minutes during the observation. The facility policy titled Medication Storage in Health Care Centers states that medications and biologicals are to be stored safely, securely, and properly, and that the medication supply is accessible only to licensed nursing personnel, certified medication aides, and pharmacy personnel. During interviews, RN DD confirmed the cart was unlocked and unattended and stated it should have been locked, and CMA EE stated she stepped away from the cart briefly to get ice.
Improper Cold Holding Temperatures for Orange Juice During Meal Service
Penalty
Summary
The facility failed to ensure that cold food, specifically orange juice, was maintained at or below 41°F in accordance with its policy titled “Food Temperatures.” The policy, revised on 10/21/2025, states that the Dietary Manager or designee is responsible for ensuring all food reaches and maintains proper temperatures prior to tray assembly, and that all potentially hazardous cold foods must be held at 41°F or less, including being held on the line in an ice bath and not set up on trays more than 15 minutes before meal service unless kept chilled. During a breakfast observation on 03/05/2026 at 7:29 a.m., a cook used the facility’s thermometer to check three four-ounce plastic containers of orange juice, which each registered above 51°F instead of the required 41°F or below. The cook acknowledged that the orange juice should have been at or below 41°F. A subsequent interview with the Registered Dietician on 03/06/2026 confirmed that cold items should be kept on ice during tray line service and that she had spoken with dietary staff about this practice. This deficiency had the potential to affect 134 of 141 residents receiving an oral diet by promoting the growth of pathogens that cause foodborne illness. No specific individual resident medical histories or conditions at the time of the deficiency were described in the report.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to ensure proper food storage and sanitation practices in the dietary department, as observed during a survey. Opened food items in the dry storage and walk-in refrigerator were not securely wrapped, labeled, or dated, and some were past their expiration dates. Specific items included expired thickened orange juice, nutritional drinks, stuffing mix, sour cream packets, cottage cheese, cream cheese icing, and a cabbage and carrot mix. Additionally, a head of lettuce was found without a label or date. The Dietary Manager (DM) acknowledged the responsibility of all staff to check expiration dates and admitted to ongoing in-services for new staff regarding storage, labeling, and dating. The DM also confirmed that the ice machine, which had not been deep cleaned since a previous date, showed signs of a reddish-black substance, indicating a lack of routine maintenance. Furthermore, the facility did not maintain sanitary cleanliness in the kitchen, as evidenced by wet nesting of clean pots, pans, and baking trays. The sanitizing process involved rewashing dishes through a low-temperature dishwasher, but wet nesting was still observed. The Registered Dietitian (RD) confirmed that kitchen audits were conducted monthly, focusing on equipment base, labeling, dating, and cleanliness. However, the RD did not physically label or date food items, relying on staff to do so when deliveries arrived. The RD also noted that she had reported the need for ice machine cleaning in the previous month's report. Both the DM and RD acknowledged the issue of wet nesting and discussed plans to address it, but these actions were not part of the deficiency findings.
Failure to Secure Medications and Assess Self-Administration
Penalty
Summary
The facility failed to assess a resident, identified as R88, for self-administration of medication and did not secure medications properly. R88, who has a diagnosis of Alzheimer's disease with early onset and dementia, was observed with pain-relieving ointments on his bedside table. Despite the facility's policy requiring a prescriber's order and an assessment for self-administration, there was no documentation or care plan indicating that R88 was authorized to self-administer these medications. Interviews with staff, including a CNA and an LPN, revealed a lack of awareness regarding R88's self-administration of medication, highlighting a gap in communication and adherence to the facility's procedures. Another resident, R43, was found with medications left unattended at her bedside, despite having intact cognition as indicated by a BIMS score of 15. The medications, which included ointments for various conditions, were reportedly left by nurses for CNAs to apply after the resident's bath. This practice was contrary to the facility's expectations, as stated by the Registered Nurse Supervisor and the Director of Nursing, who both emphasized that medications should not be left unattended in residents' rooms. Interviews with CNAs confirmed that this was a recurring issue, with medications being left at the bedside at least twice a week. The deficient practices observed in both cases had the potential to allow unauthorized access to medications by residents and visitors, posing a risk of medication interactions or overmedication. The facility's failure to adhere to its own policies regarding medication security and self-administration assessments contributed to these deficiencies, as evidenced by the lack of proper documentation and communication among staff members.
Failure to Conduct PASRR Level Two Screening for Resident with Mental Illness
Penalty
Summary
The facility failed to conduct a Pre-Admission Screening and Resident Review (PASRR) level two for a resident diagnosed with paranoid schizophrenia, which is a significant mental illness. The facility's policy requires that residents with significant mental illness or intellectual/developmental disabilities undergo a PASRR level two assessment to ensure they receive care in the most integrated setting appropriate to their needs. However, the resident, who was admitted with a diagnosis of paranoid schizophrenia and was taking anti-psychotropic and anti-depressant medications, was not screened for PASRR level two. The care plan for the resident included interventions for paranoid schizophrenia and bipolar disorder, but there was no focus area for PASRR level two screening. Interviews with facility staff, including the RN Supervisor, Director of Nursing, and Social Services Director, revealed that the resident was not referred for a PASRR level two assessment because she did not exhibit any behaviors that would trigger such a referral. The Social Services Director confirmed that the resident was not referred for PASRR level two, as the facility's practice was to refer residents only if they exhibited behaviors indicative of a major mental disorder. This oversight had the potential to prevent the resident from receiving necessary specialized services.
Failure to Clean Shared Blood Pressure Cuff
Penalty
Summary
The facility failed to adhere to its policy on cleaning and disinfecting shared medical equipment, specifically a blood pressure cuff, before and after use between residents. The policy, reviewed on 12/29/2023, mandates that shared equipment such as blood pressure cuffs and pulse oximeters be cleaned with soap and water or an appropriate cleaner and then disinfected prior to and after use on different patients. However, an observation on 9/4/2024 revealed that a Certified Nurses Aid (CNA) did not clean the blood pressure cuff between taking vital signs of two residents in the same room. The CNA was observed removing the electronic blood pressure cuff from one room and using it on two residents without cleaning it in between. When questioned, the CNA initially claimed to have cleaned the cuff but later admitted she had not done so, citing nervousness. The Assistant Director of Nurses confirmed that the protocol requires cleaning before and after each use. The CNA was seen searching for disinfecting wipes at the nurse's station after completing her rounds, indicating a lapse in following the established infection control procedures.
Failure to Resolve Grievances Related to Lost Personal Items
Penalty
Summary
The facility failed to appropriately resolve grievances related to lost personal items for three residents. The facility's grievance policy requires that grievances be resolved within a reasonable time frame and that the complainant be kept informed of the progress. However, the facility did not adhere to this policy. For one resident, multiple clothing items went missing in April 2023, but only one unrelated grievance was documented in December 2023. The family expressed distrust in the facility's ability to keep items safe. Another resident filed a grievance for missing clothing in February 2024, but no follow-up was completed until the survey investigation in March 2024. A third resident filed a grievance in September 2022 for missing a large amount of clothing, but no resolution was documented. Interviews with facility staff revealed a lack of clear procedures and accountability in handling grievances and lost items. The Administrator acknowledged the need for improvement in the lost and found process and the absence of a policy for laundry services. The Social Service Specialist indicated that grievances should be investigated and followed up within 14 days, but this was not consistently done. The Laundry Staff reported issues with labeling and returning laundry, and unclaimed items were kept in a container for an unknown period. The facility's failure to follow its grievance policy and effectively manage lost items led to unresolved grievances and dissatisfaction among residents and their families.
Failure to Offer Resident Scheduled Showers
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not offering her the choice of showers, which was part of her care plan. The resident, identified as R2, was a bilateral amputee with end-stage renal disease on hemodialysis. Despite being cognitively intact and expressing a preference for showers, she was not offered this option. The facility's records showed that R2 was scheduled for showers on Mondays and Thursdays, but she often received bed baths instead. Interviews with staff revealed a lack of awareness and understanding of R2's preferences and care plan, leading to her not being offered showers. The Dialysis Social Worker reported that R2 arrived for treatment in the same clothes over several days and had poor hygiene, indicating a lack of proper bathing. The Director of Nursing confirmed that R2 was care planned for showers twice a week but was not on the daily showers list, and her shower days coincided with her dialysis days, which did not accommodate her needs. This oversight resulted in R2 not receiving showers as per her care plan, affecting her comfort and hygiene.
Failure to Implement Resident's Bathing Preferences
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident, identified as R2, regarding her bathing preferences. R2, a bilateral amputee with end-stage renal disease on hemodialysis, was cognitively intact and expressed that it was somewhat important for her to choose between different bathing options. Despite this, the facility's ADL care plans did not include her preferences for showers or baths. The care plans dated March 13, 2024, lacked any goals or interventions related to her bathing preferences. Observations and interviews revealed that R2 was not offered showers as per her care plan, which stated she should receive showers on Wednesday and Saturday evenings. Instead, she was given bed or sponge baths, and staff were unaware of her preference for showers. The Director of Nursing confirmed that R2 was not on the Daily Showers list, despite being care planned for showers twice a week. This oversight led to R2 receiving only one shower since her admission in November 2023.
Mechanical Lift Readiness Deficiency
Penalty
Summary
The facility failed to maintain mechanical lifts in a state of readiness, impacting the care of a resident with significant mobility and cognitive impairments. The resident, who has a history of arthritis, Alzheimer's Disease, cerebrovascular accident, dementia, and hemiplegia or hemiparesis, was observed to be dependent on mechanical lifts for all activities of daily living. During an observation, multiple mechanical lifts were found in the hallways, not in use, and most were not plugged into power sockets, rendering them unavailable for immediate use. On a subsequent observation, a resident was found in discomfort, requesting assistance to be moved from a wheelchair to a bed. A CNA indicated that the mechanical lift near the resident's room was not charged, necessitating a wait for assistance. The Director of Nursing acknowledged issues with the mechanical lifts, noting that new lifts had been purchased and additional ones were approved for purchase. Despite an in-service training, the deficiency persisted, as staff were expected to ensure all lifts were charged and ready for use.
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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