Pruitthealth - Palmyra
Inspection history, citations, penalties and survey trends for this long-term care facility in Albany, Georgia.
- Location
- 1904 Palmyra Road, Albany, Georgia 31702
- CMS Provider Number
- 115628
- Inspections on file
- 21
- Latest survey
- November 24, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Pruitthealth - Palmyra during CMS and state inspections, most recent first.
The facility did not develop or implement care plan interventions for routine weekly skin assessments for multiple residents at risk for pressure ulcers, resulting in missed assessments and delayed identification of new or worsening wounds. Several residents with significant risk factors, including those with existing pressure ulcers and severe cognitive or physical impairments, did not receive the required weekly skin inspections as outlined in facility policy.
Multiple high-risk residents did not receive consistent weekly skin assessments or timely wound care treatments as ordered, resulting in delayed identification and management of pressure ulcers. Gaps in documentation, missed treatments, and unclear staff responsibilities contributed to the deficiency, with several residents developing new or worsening wounds that were only discovered during a facility-wide skin sweep.
Administration did not ensure that licensed nurses consistently performed and documented weekly skin assessments and wound treatments as ordered, impacting six residents at risk for or with existing wounds. The facility also lacked effective oversight and a QAPI process for its skin integrity program, and did not develop a Performance Improvement Plan despite identified issues. Staffing instability further contributed to lapses in wound care and documentation.
The facility's QAPI committee did not provide effective oversight to ensure staff performed weekly skin assessments, resulting in missed identification and treatment of pressure ulcers. Despite wound care issues being identified and recommendations for a Performance Improvement Plan, the facility did not implement timely corrective actions or conduct required audits, leading to a situation with the likelihood to cause serious harm to residents.
The facility did not have a Certified Dietary Manager (CDM) overseeing the kitchen after the previous CDM left, and the Registered Dietitian did not fully assume responsibility for the Dietary Services Department. Staff interviews and observations showed that cleaning schedules and duty assignments were not maintained, and dietary staff operated without clear direction, impacting the provision of oral meals to most residents.
Surveyors identified multiple deficiencies in food service operations, including unsanitary conditions in the ice machine, improper dishwashing procedures, inadequate food storage and labeling, and unclean kitchen floors. Staff failed to follow proper sanitation protocols for both equipment and food handling, and the dishwasher did not consistently reach required temperatures for effective sanitation.
The facility did not ensure that grievances raised by residents during council meetings were tracked, resolved, or communicated back to the residents, as required by policy. Staff interviews confirmed that while complaints were documented and forwarded to department heads, there was no consistent follow-up or resolution process in place.
The facility experienced repeated delays in meal service, with observations showing backlogs of dirty dishes and late delivery of meals, including the use of Styrofoam containers when plates were unavailable. An LPN and a CNA confirmed late meal deliveries, and a resident reported consistently late dinners. The Dietary Supervisor cited dishwashing issues and a shortage of dry plates as causes for the delays, affecting the majority of residents receiving oral diets.
Three cognitively intact residents who wished to vote in the November 2024 election were not assisted by staff with obtaining absentee ballots or renewing necessary identification, despite available resources and a visit from voter registrars. Staff interviews confirmed a lack of follow-up and awareness regarding which residents wanted to vote.
The facility did not promptly notify a physician about a resident's repeated episodes of low blood pressure and fainting, nor did it inform a responsible party about another resident's diagnostic test results and a new leg wound. These failures involved residents with complex medical conditions and resulted in missed communication regarding significant changes in condition and care.
A resident admitted with an indwelling Foley catheter, and with multiple complex diagnoses, did not have a physician's order for the catheter documented in their medical record. Facility policy required verification of such orders, but this was not completed, and staff confirmed the ongoing use of the catheter without a physician's order.
A resident with intact cognition and a documented dislike for broccoli was served broccoli at lunch, despite the facility's policy to honor food preferences. The resident reported not being asked about menu choices and regularly receiving unwanted foods.
A resident with multiple complex medical conditions developed a Stage 2 pressure ulcer that was not consistently or thoroughly assessed and documented according to facility policy. After the initial identification and measurement, no further weekly wound assessments were recorded until the resident was seen by an outside wound care clinic, and no subsequent documentation was found before the resident's discharge.
A resident with an unsteady gait and intermittent confusion slipped and fell in the memory care unit after water leaked from the ceiling, with trash cans placed to collect the water. The roof had a history of leaks, and although temporary fixes and repair quotes were documented, no permanent repairs had been completed, resulting in a persistent hazard.
A resident with multiple complex medical conditions experienced significant, unmonitored weight loss over several months. The facility did not follow its own policy for re-weighing, weekly weight monitoring, or timely referral to a Registered Dietician. Additionally, a Speech Therapy evaluation for swallowing difficulties was not ordered until prompted by a surveyor, despite earlier indications it was needed.
A resident with multiple sclerosis and other conditions did not receive scheduled doses of Kesimpta for several months due to late or missing pharmacy deliveries and lack of timely ordering. Medication administration records and staff interviews confirmed that the medication was not available on the scheduled dates, resulting in missed doses.
Failure to Develop and Implement Weekly Skin Assessment Interventions in Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans with measurable interventions and timetables for residents at risk for skin breakdown, as required by its own policy. Specifically, the care plans for several residents did not include interventions for routine weekly skin assessments, and for some residents, the existing care plan interventions for weekly skin inspections were not implemented. This deficiency was identified through observation, record review, and interviews, revealing that multiple residents with significant risk factors for pressure ulcers did not receive timely or documented weekly skin assessments. For example, one resident with end stage renal disease, diabetes, and a history of pressure ulcers had a care plan that lacked interventions for routine weekly skin assessments, and documentation showed missed weekly assessments over several months. Another resident with multiple Stage III and IV pressure ulcers and severe cognitive impairment also had a care plan without weekly skin assessment interventions, and only two assessments were documented over a two-month period. Additional residents with high or moderate risk for skin breakdown, as indicated by Braden Scale scores and other medical conditions, similarly lacked appropriate care plan interventions or did not receive weekly skin assessments as required. In several cases, new or worsening pressure ulcers were only identified during a facility-wide skin sweep, rather than through ongoing, routine monitoring. The surveyors determined that the facility's noncompliance with care planning and implementation requirements had caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The deficiency was found to have existed for several months prior to the survey, affecting multiple residents with complex medical histories and significant risk factors for skin breakdown. The facility's own policy required person-centered care plans with measurable goals and regular updates, but these requirements were not met for the residents reviewed.
Failure to Consistently Assess and Treat Pressure Ulcers in High-Risk Residents
Penalty
Summary
The facility failed to perform consistent weekly skin assessments for residents at high risk for skin breakdown, resulting in delayed identification of pressure ulcers and inadequate documentation. Multiple residents with significant risk factors, such as immobility, cognitive impairment, and existing wounds, did not receive the required weekly skin assessments as outlined in the facility's own policy. For example, one resident with a history of Stage IV sacral pressure ulcer and multiple comorbidities did not have weekly skin assessments documented for several months, and new or recurrent wounds were only identified during a facility-wide skin sweep prompted by concerns about another resident. Other residents at high risk, including those with severe cognitive impairment, paraplegia, and malnutrition, also had significant gaps in their skin assessment documentation, with some going weeks or months without any recorded assessment. In addition to the lack of timely skin assessments, the facility failed to perform wound treatments as ordered by physicians or recommended by the wound care nurse practitioner for several residents. Medication Administration Records (MARs) revealed missed wound care treatments on multiple occasions, and in some cases, treatments were not initiated until days after wounds were identified. For instance, one resident with multiple Stage III and IV pressure ulcers had several missed wound care treatments, and another resident with an unstageable pressure ulcer to the left heel did not receive a physician's order or treatment until two days after the wound was first identified. There were also instances where wound care orders were not restarted after a resident returned from the hospital, resulting in a lack of wound care for over a month. Interviews with staff and review of facility records indicated systemic issues with the implementation and oversight of the skin integrity and wound care program. Staff responsible for weekly skin assessments were not consistently performing them, and there was confusion or lack of accountability regarding who was responsible for monitoring the program. High turnover among treatment nurses contributed to inconsistent documentation and missed treatments. The facility's own leadership acknowledged gaps in the completion of Braden Scale assessments and weekly skin audits, as well as difficulties in maintaining adequate staffing for wound care. These failures led to the delayed identification and treatment of pressure ulcers in multiple high-risk residents.
Failure to Ensure Weekly Skin Assessments and Oversight of Wound Management
Penalty
Summary
Administration failed to ensure that staff performed weekly skin assessments and wound treatments as ordered, and did not provide adequate oversight and monitoring of the skin integrity program. This deficiency affected six residents who were either at risk for skin breakdown or had existing wounds. Specifically, weekly skin inspections were not implemented for two residents, and interventions for routine weekly skin assessments were not developed for four other residents at risk for skin breakdown. Additionally, licensed nursing staff did not consistently perform or document weekly skin assessments and treatment orders for several residents. The facility also did not utilize an effective Quality Assurance and Performance Improvement (QAPI) process to identify and address concerns related to the wound management system. Despite recommendations from the Regional Nurse Consultant to develop a Performance Improvement Plan after identifying problems with the skin management program, there was no indication that such a plan was created. Staffing instability was noted, with five treatment nurses employed over several months and periods when only one treatment nurse was available, making documentation and wound care challenging.
Failure of QAPI Oversight for Weekly Skin Assessments
Penalty
Summary
The facility failed to have an effective Quality Assurance and Performance Improvement (QAPI) committee that provided oversight and monitoring to ensure staff were performing weekly skin assessments for timely identification and treatment of pressure ulcers. Review of the QAPI committee meeting agendas and minutes for two meetings showed no indication that the committee identified the staff's failure to perform these assessments. The facility's policy required a comprehensive, data-driven QAPI program with regular review and prioritization of performance improvement projects (PIPs), but there was no evidence that a PIP addressing wound care or skin assessments was implemented in a timely manner, despite identified problems. Interviews revealed that the Regional Nurse Consultant had identified wound care issues and recommended a PIP, but the facility did not act on this recommendation. Additionally, required monthly audits for residents with wounds were not completed. The Administrator acknowledged that a PIP was not implemented until after the survey team arrived, and attributed missed actions to ongoing leadership changes. The noncompliance was determined to have caused or had the likelihood to cause serious injury, harm, impairment, or death to residents.
Failure to Employ Certified Dietary Manager and Ensure Dietitian Oversight
Penalty
Summary
The facility failed to employ a Certified Dietary Manager (CDM) to oversee the kitchen and did not ensure that the Registered Dietitian assumed full responsibility and accountability for the Dietary Services Department. Observations revealed that after the former CDM's last day, there was no CDM present in the kitchen, and the duties were not being properly managed. The facility's job descriptions for both the Dietitian and Dietary Manager outlined responsibilities for oversight, quality assurance, and staff direction, but these were not being fulfilled due to the absence of a CDM. On one occasion, a CDM from an affiliated facility was observed overseeing the kitchen, but this was not a consistent arrangement. Interviews with staff indicated that the Registered Dietitian attempted to assist the dietary supervisor but was not able to fully assume the required responsibilities. The Dietary Supervisor admitted to not making cleaning schedules or duty assignments, resulting in staff cleaning as they saw fit without assigned responsibilities. The staff list provided by the facility confirmed the absence of a CDM, and the Administrator acknowledged that the former CDM had left and had not been replaced. The deficiency affected the provision of oral meals to 184 of 203 residents.
Widespread Food Service Sanitation and Storage Deficiencies
Penalty
Summary
Multiple deficiencies were identified in the facility's food service operations, including improper sanitation and maintenance of kitchen equipment and surfaces. Observations revealed that the ice machine contained visible black and pink substances on the chute, and the ice bin was dirty and left open to air. Staff interviews confirmed that the ice machine had never been sanitized with the appropriate cleaning solution since its purchase, as the cleaning solution had never been ordered. Additionally, the kitchen floors were found to have food debris, dirt, and dried spills, and blankets were used on the floor to absorb water from a leaking dishwasher sprayer. The facility failed to ensure proper dishwashing procedures, as the dishwasher did not consistently reach the required water temperatures for effective sanitation, and the three-compartment sink was not used according to manufacturer recommendations. Staff were observed washing pots and pans without using the rinse or sanitizer steps, and sometimes dried cookware with cloth towels instead of allowing them to air dry. Instructional posters for proper sink use were present, but staff did not consistently follow them. The dishwasher was temporarily converted to use chlorine sanitizer due to ongoing hot water issues, but water temperatures remained below recommended levels during multiple cycles. Food storage and handling practices were also deficient. Opened food items in the walk-in refrigerator, such as turkey breast slices, cheddar cheese, liquid eggs, and cornbread, were not properly dated or labeled. Food on the steam table was observed at temperatures below 135°F, and clean dishes were stored on surfaces with visible food particles. Scoops were stored inside dry goods bins instead of in designated holders, and a no-touch trash can was not available near the sink, leading staff to use a large trash can with a lid that was manually opened. These practices had the potential to increase the spread of foodborne illness among residents receiving oral diets.
Failure to Address and Resolve Resident Grievances
Penalty
Summary
The facility failed to address and resolve grievances raised by residents during council meetings for four out of seven months reviewed. Record review showed that issues such as lack of tea, late meals, inability to eat in the dining room on weekends, timing of evening meals, absence of coffee, and broken kitchen equipment were documented in the Patient/Resident Council Minutes/Report Forms. However, there was no evidence that these grievances were tracked, resolved, or that written decisions were issued to the individuals who filed them, as required by the facility's grievance policy. Interviews with staff revealed that while the Activity Director documented complaints and forwarded them to the relevant department heads, there was no follow-up with residents regarding the outcomes of their grievances. The Social Worker (BSW) confirmed that grievances were discussed in morning meetings but was not involved in resolving them, and the Social Worker (MSW) had not previously reviewed grievances from the council minutes. The Administrator acknowledged that staff should be educated on the grievance process and that any staff member could write a grievance, but the process for tracking and resolving grievances was not consistently followed.
Delayed Meal Service Due to Dishwashing Backlog and Plate Shortage
Penalty
Summary
The facility failed to ensure that resident meals were served in a timely manner, as required by posted mealtimes and resident needs. Multiple observations during kitchen visits revealed significant delays in dishwashing, with breakfast dishes remaining unwashed late into the morning and a backlog of dirty dishes waiting to be cleaned. These delays contributed to late meal service, as evidenced by lunch trays being delivered well after the scheduled lunch time on several occasions, including meals being served in Styrofoam containers due to a shortage of clean plates. Staff interviews confirmed that meal delivery was consistently late, with one resident reporting that dinner often arrived between 6:30 pm and 8:00 pm, despite the posted supper time of 4:30 pm. The Dietary Supervisor acknowledged responsibility for ensuring timely meal service and attributed the delays to issues with the dishwasher and insufficient dry plates for the next meal. The facility had recently purchased additional dinner plates, but this measure had not resolved the ongoing delays. The deficiency had the potential to affect 184 of 203 residents who received an oral diet, as timely meal service was not consistently maintained according to residents' needs, preferences, and posted schedules.
Failure to Assist Residents with Voting Rights
Penalty
Summary
The facility failed to assist three residents with the process of voting in the November 2024 election, despite their expressed wishes and cognitive ability to do so. Resident 14, who had intact cognition and significant physical disabilities, reported needing help to renew his state identification card in order to vote, but did not receive any assistance. Resident 28, also cognitively intact, had the necessary identification but was not provided with an absentee ballot or assistance to obtain one, despite her desire to vote. Resident 29, a registered voter, similarly did not receive an absentee ballot and expressed that he wanted to vote. Interviews with facility staff revealed a lack of follow-up and organization regarding residents' voting needs. The social worker with a master's degree stated she would survey residents with a BIMS score greater than 10 to determine voting interest and assist with identification, but was not employed during the relevant election period. The social worker with a bachelor's degree acknowledged that voter registrars had visited the facility but did not know which residents wanted to vote or provide follow-up assistance. The county voter registrar confirmed that resources were available online for assisting with voter registration and absentee ballots, but these were not utilized by the facility for the residents in question.
Failure to Notify Physician and Responsible Party of Significant Changes and Test Results
Penalty
Summary
The facility failed to ensure timely notification of a physician regarding abnormal vital signs for one resident and did not notify the responsible party about diagnostic test results and a new skin impairment for another resident. For one resident with multiple diagnoses including heart disease, hypertension, and hypotension, therapy staff documented several episodes of low blood pressure and fainting during therapy sessions. Despite these significant changes in condition, there was no documentation that the physician or nurse practitioner was notified of the abnormal blood pressure readings until several days later, even though the therapy staff requested physician input regarding blood pressure parameters and medication regimen. For another resident with dementia, diabetes, and a gastrostomy, the facility failed to notify the responsible party of a diagnostic procedure to verify gastrostomy tube placement and did not communicate the results. Additionally, the responsible party was not informed about a new wound on the resident's leg, which was discovered during an observation with nursing staff. The nurse responsible for skin integrity was unaware of the wound prior to the observation, and there was no evidence that appropriate orders were obtained for the dressing applied to the wound.
Failure to Obtain Physician Order for Indwelling Catheter
Penalty
Summary
A resident with multiple complex medical conditions, including malignant neoplasm of the prostate, Stage IV pressure ulcer, multiple myeloma not in remission, paraplegia, and a colostomy, was admitted to the facility from a hospital with an indwelling Foley catheter in place. Review of the resident's admission orders and all subsequent orders up to several months after admission revealed there was no physician's order for the continued use of the indwelling urinary catheter. Facility policy for indwelling urinary catheters required verification of orders, but this step was not followed. Nursing progress notes documented the presence and replacement of the Foley catheter, and staff interviews confirmed the ongoing use of the catheter without a physician's order.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor a resident's documented food preferences as required by its policy and regulatory standards. According to the resident's medical record, the individual had intact cognition and had clearly indicated a dislike for broccoli on the Diet Review/Food & Beverage Preference List. Despite this, an observation of the resident's lunch meal tray revealed that broccoli was served. The resident reported never being asked about menu choices and consistently receiving foods he did not like, such as broccoli. The facility's policy states that food preferences and choices should be honored within reason according to the resident's diet order and available menu selections, but this was not followed in this instance.
Failure to Consistently Assess and Document Pressure Ulcer
Penalty
Summary
The facility failed to thoroughly and consistently assess and document a pressure ulcer for one resident, as required by its own policy. The policy mandates weekly wound observations and comprehensive nursing assessments, including detailed measurements and descriptions of the wound and surrounding tissue. For the resident in question, who had multiple diagnoses including hemiplegia, vascular dementia, and was dependent on staff for all activities of daily living, a Stage 2 pressure ulcer was identified and measured on the sacrum. However, after the initial assessment, there were no further wound assessments or measurements documented for over a month, until the resident was evaluated by an external wound care clinic. Following the wound care clinic's evaluation, there continued to be no further assessments of the sacral pressure ulcer documented in the clinical record. The resident was later discharged to the hospital. The Director of Health Services confirmed that there was no weekly descriptive documentation of the resident's pressure ulcer, as required by facility policy.
Resident Fall Due to Ongoing Ceiling Leak
Penalty
Summary
A deficiency occurred when a resident slipped and fell due to water leaking from the ceiling in the memory care unit. Observations revealed that water was actively leaking from the ceiling, with trash cans placed on the floor and a table to collect the dripping water. The incident involved a resident who was ambulatory with an unsteady gait, used a cane, and was sometimes confused. The fall happened in the dayroom, and there was no documented injury as a result of the incident. Review of facility records and staff interviews indicated that the roof had a history of leaking, particularly during heavy rain, and that temporary measures such as applying tar had been used. Multiple invoices and proposals for roof repairs were present, but none specified the exact section needing repair, and no repairs had been completed in 2024. The Maintenance Director confirmed the ongoing nature of the leak and the lack of permanent repairs, contributing to the continued presence of the hazard.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to monitor and address significant weight loss for one resident, who had multiple diagnoses including hemiplegia, dysphagia, diabetes, and major depressive disorder. Despite the facility's policy requiring weekly weights and re-weighs for significant weight changes, the resident experienced an 8.2% weight loss in one month, a 16.4% loss in three months, and a 23.6% loss in six months. There was no evidence that the resident was re-weighed after the initial significant weight loss, nor was the Registered Dietician consulted in a timely manner. The resident was not placed on weekly weights as required by policy, and the Weight Loss/Gain Checklist and other interventions were not documented as completed. Additionally, the resident reported coughing and choking with eating, which prompted a Nurse Practitioner to order a Speech Therapy (ST) evaluation. However, the ST evaluation was not ordered until after the state surveyor's inquiry, despite the earlier recommendation. The Director of Health Services confirmed that the required re-weigh and dietician notification did not occur, and the ST evaluation order was delayed.
Failure to Ensure Timely Ordering and Administration of Specialty Medication
Penalty
Summary
The facility failed to ensure timely ordering and administration of Kesimpta, an injectable medication used to treat multiple sclerosis, for one resident. Observations revealed that the medication was present in the refrigerator on one date but missing on a subsequent date when the next dose was due. Review of the resident's records showed that Kesimpta was not administered for several months, specifically in April, May, June, and July, due to the medication being unavailable or not delivered on time. Pharmacy delivery records confirmed late deliveries in April, May, and July, and no evidence of delivery in June. Medication administration records also indicated that the medication was not given because it was not available on the scheduled dates. The resident involved had multiple diagnoses, including multiple sclerosis, cognitive communication deficit, seizures, and hypertension. Staff interviews confirmed that the medication was not administered when it was not available, and the Director of Health Services acknowledged that specialty medications due monthly should be ordered prior to the due date. There was no evidence that the resident received Kesimpta for the months in question, resulting in a failure to comply with requirements for timely medication ordering and administration.
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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