Pruitthealth - West Atlanta
Inspection history, citations, penalties and survey trends for this long-term care facility in Atlanta, Georgia.
- Location
- 2645 Whiting Street N.w., Atlanta, Georgia 30318
- CMS Provider Number
- 115512
- Inspections on file
- 22
- Latest survey
- December 17, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Pruitthealth - West Atlanta during CMS and state inspections, most recent first.
A resident with cognitive impairment and extensive care needs experienced an unwitnessed fall and was later found to have a femur fracture after being hospitalized. The facility's investigation into the injury of unknown source was incomplete, as it did not include interviews with direct care staff, the resident, the resident's representative, or other relevant individuals, and only two statements from department heads were collected. This did not meet the facility's own policy requirements for investigating such incidents.
A resident with a documented NPO status and gastrostomy tube order was given a food tray, resulting in the resident being found with food in their mouth. This failure to follow the care plan was followed by a significant decline in the resident's respiratory status, requiring hospital transfer and intensive care interventions.
A resident with a history of dysphagia, pneumonia, and a G-tube was repeatedly provided food despite NPO orders, due to failures in staff assessment, communication, and the meal ticket system. The resident was given sandwiches and later a food tray, resulting in aspiration events and hospitalizations. Staff interviews confirmed that dietary orders were not properly clarified or communicated, and the facility's policies for reviewing and implementing specialized diets were not followed.
The facility failed to prevent two garbage dumpsters from overflowing, which prohibited the lids and side doors from closing, creating a potential for pests, rodents, and insects. One dumpster was also missing a plug, leading to potential leakage of garbage contaminants. The Dietary Manager and Maintenance Director confirmed the issues, with the latter unaware of the overflow and missing plug.
The facility failed to ensure a dignified dining experience for three residents. One resident received breakfast 10 minutes after others, another was the last to receive lunch, and a resident was pulled backwards in a geriatric chair. Staff were also heard referring to residents as 'feeders'. The DHS confirmed these actions were inappropriate and indicated a lack of staff training on resident dignity.
The facility failed to provide bed hold information in writing at the time of transfer or within 24 hours for three residents transferred to the hospital in the last 120 days. Staff interviews revealed a lack of awareness and clarity about who was responsible for providing the bed hold notices, and the required documentation was not provided.
The facility failed to ensure that residents were seen by a physician at the required intervals, with four residents not receiving the mandated visits. Staff interviews confirmed the requirement for regular visits, but the protocol was not followed, leading to the deficiency.
The facility failed to ensure all food items on the steam table were held above 135°F, affecting nine residents on a puree diet. The puree beef patty was found at 132°F, and the Dietary Manager confirmed the deficiency.
A resident with multiple diagnoses was found with over-the-counter medications at her bedside without being assessed for the ability to self-administer. An LPN confirmed the oversight and removed the items, and the Director of Health Services was unaware of the situation prior to it being reported.
The facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to a resident who was discharged from Medicare Part A coverage and remained in the facility. The Financial Controller was unaware of the requirement, and the resident and/or the responsible party did not receive the necessary notice.
A facility failed to provide specialized psychiatric services for a resident with schizophrenia as recommended by the PASRR Level II summary. Despite having a care plan and being on antipsychotic medication, there was no documented evidence that the resident received the necessary psychiatric and psychotherapy services.
The facility failed to develop care plans for antipsychotic and anti-anxiety medications for a resident with dementia and anxiety, and did not adhere to dietary restrictions for another resident with a lactose allergy, leading to potential gaps in treatment and care.
A resident with a documented lactose allergy was repeatedly served food items containing lactose, despite clear indications on the meal tray ticket and physician orders. The Dietary Manager confirmed the oversight and revealed the absence of a facility policy regarding therapeutic diets and food allergies.
A resident with dementia and anxiety was receiving multiple psychotropic medications, including haloperidol. The facility failed to conduct an annual Gradual Dose Reduction (GDR) assessment for the resident's antipsychotic medication, as required by their policy. The last documented GDR was over a year ago, and this deficiency was confirmed by the Director of Health Services.
The facility failed to ensure medications were dated when opened, discarded on the discard dates, and stored according to manufacturer recommendations on one of three medication carts. Observations revealed several medications were either not labeled with open and discard dates or were stored improperly. Interviews confirmed that all nurses and Unit Managers were responsible for ensuring proper storage, labeling, and discarding of medications.
The facility failed to ensure the ice scoop bin and beverage dispenser were free from green and black buildup on one unit. Observations revealed that the ice scoop was stored in a container with black buildup and used by CNAs to deliver ice to residents. The water dispenser also had green and black buildup. Staff confirmed the buildup and the lack of a cleaning schedule for the ice scoop.
Failure to Thoroughly Investigate Injury of Unknown Source
Penalty
Summary
The facility failed to thoroughly investigate a serious bodily injury of unknown source for one of ten sampled residents. The resident in question had multiple diagnoses, including cognitive communication deficit, vascular dementia, and required extensive assistance with activities of daily living. The resident experienced a fall that was unwitnessed, and later was found to have a right femur intertrochanteric fracture, which was discovered only after the resident was sent to the hospital for unrelated symptoms. The facility's policies required that, in the event of an injury of unknown source, interviews should be conducted with the resident, staff who provided care, other residents, and any pertinent outside sources, as well as gathering signed statements and observing the resident for behavioral clues to the injury's cause. Upon review, the investigation conducted by the facility was found to be incomplete. Only two witness statements were collected, both from department heads, and there was no evidence that direct care staff, the resident, the resident's representative, other residents, or outside sources were interviewed. There was also no documentation of observations of the resident or an evaluation of whether the resident felt safe. The investigation did not address the potential connection between the unwitnessed fall and the subsequent discovery of the fracture. Interviews with facility staff, including a Certified Medication Aide, the Unit Manager, the Director of Health Services, and the Administrator, confirmed that the standard practice was to collect statements for injuries of unknown source but not for unwitnessed falls. The Administrator, who served as the abuse coordinator, stated that the investigation was inconclusive and acknowledged that not completing a thorough investigation could result in not finding the true root cause. The documentation provided by the facility was confirmed to be the complete investigation, which lacked the required thoroughness as outlined in facility policy.
Failure to Follow NPO Care Plan Resulting in Resident Harm
Penalty
Summary
A deficiency occurred when the facility failed to follow the care plan for a resident who was designated as nothing by mouth (NPO) due to multiple diagnoses, including pneumonia, dysphagia, respiratory failure with hypoxia, and cognitive communication deficit. The resident's care plan, initiated on 10/16/2025, specified the use of a gastrostomy tube for nutrition and water flushes as ordered, with a physician's order confirming NPO status. Despite these documented interventions, the resident was observed with a food tray and food in his mouth, specifically three shrimps, on 11/15/2025. The incident was documented in the electronic medical record, and the kitchen staff was subsequently educated about the resident's NPO status. Following this event, the resident experienced a significant change in condition, including decreased oxygen saturation and respiratory distress, which required escalation of oxygen therapy and eventual transfer to the hospital. Hospital records indicated the resident was admitted with acute respiratory distress, hypoxic respiratory failure, and required intensive care interventions, including thoracentesis and ventilatory support. The Director of Health Services confirmed that the resident's NPO restriction was documented in the care plan and acknowledged that the care plan was not followed when the resident was given a food tray.
Failure to Follow NPO Orders and Ensure Nutritional Safety
Penalty
Summary
The facility failed to provide appropriate nutritional treatment and services for a resident with dietary orders for nothing by mouth (NPO). Upon admission, the resident had a history of pneumonia, dysphagia, respiratory failure, and required a gastrostomy tube (G-tube) for nutrition. Despite clear orders and documentation indicating the resident was NPO and at high risk for aspiration, staff did not properly assess or clarify dietary needs at admission. On the day of admission, an LPN provided the resident with two ham and cheese sandwiches and ice water, without confirming the hospital discharge orders or recognizing the presence of a G-tube. This resulted in the resident aspirating and subsequently being hospitalized for aspiration pneumonia. The deficiency was further compounded when, after the resident's return to the facility, a food tray was again provided to the resident despite ongoing NPO orders and clear recommendations from speech therapy. The meal ticket system failed to reflect the correct NPO status, and a CNA unfamiliar with the resident gave the food tray, which led to the resident having food in his mouth. The error was identified and corrected by a supervisor, but not before the resident was exposed to further risk. Interviews with staff confirmed that communication breakdowns occurred between nursing, dietary, and therapy departments, and that the meal ticket system did not always accurately display specialized diets. Throughout the resident's stay, there were multiple documented instances of aspiration, pneumonia, and hospitalizations directly related to the failure to follow NPO orders. Staff interviews revealed that the admitting nurse did not verify discharge orders upon admission, and that subsequent communication lapses and system errors led to repeated provision of food to the resident. The facility's own policies required timely review and clarification of dietary orders, but these were not consistently followed, resulting in the resident not receiving the necessary care and services to meet nutritional needs.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to prevent two garbage dumpsters from overflowing with excess garbage, which prohibited the top lids and side doors from closing. This situation created a potential for pests, rodents, and insects. Observations revealed that one dumpster had trash bags overflowing from the top and sides, while the other had a large cardboard box and a garbage bag with a tan-colored liquid hanging out of the side door. Additionally, one of the dumpsters was missing a plug, which could lead to potential leakage of garbage contaminants. The Dietary Manager confirmed the overflow and the missing plug, stating that the dumpsters are emptied daily by a waste management company, and he makes rounds two to three times a day to ensure the area is clean. The Maintenance Director revealed that the dumpsters are emptied twice a week, typically in the afternoon, and that early pick-up can be arranged if needed. However, he was not aware that the dumpsters were full and overflowing and did not realize that one of the dumpsters was missing a plug. The Maintenance Director mentioned that he would likely need to purchase a plug to address the issue. The facility census was 101 residents at the time of the observation.
Failure to Ensure Dignified Dining Experience
Penalty
Summary
The facility failed to ensure a dignified dining experience for three residents on the [NAME] Unit. Specifically, one resident did not receive her breakfast until 10 minutes after others had already been served and some had finished eating. Another resident was the last to receive her lunch tray, which led her to question staff about the delay. Additionally, a resident was pulled backwards in his geriatric chair by an LPN when leaving the dining area, and staff were heard referring to residents as 'feeders' during lunch. These actions were observed during meal times and were corroborated by staff interviews. The Director of Health Services (DHS) was unaware of these incidents and confirmed that residents should be treated with respect, receive meals at the same time, and not be referred to as 'feeders'. The DHS also stated that residents in geriatric chairs should not be pulled backwards. The facility's document titled 'Your Rights as a Patient' emphasizes the right to be treated with respect and dignity, which was not upheld in these instances. Interviews with staff revealed a lack of training related to the dignity of residents, contributing to the observed deficiencies.
Failure to Provide Bed Hold Information at Time of Transfer
Penalty
Summary
The facility failed to provide bed hold information in writing at the time of transfer or within 24 hours for three residents who were transferred to the hospital in the last 120 days. The facility policy requires that a bed hold notice be given during admission and another at the time of transfer. However, for Resident 106, there was no documented evidence of a bed hold notification being provided when the resident was transferred to the hospital. Interviews with staff, including LPNs and the Admissions Coordinator, revealed a lack of awareness and clarity about who was responsible for providing the bed hold notices. The Director of Health Services confirmed that the required documentation was not provided for Resident 106's transfer on 3/31/2024. Similarly, Resident 68 was transferred to the hospital on 4/8/2024, and there was no evidence in the EMR that a bed hold policy was provided. Interviews with the Financial Counselor and LPN Unit Manager indicated that nursing staff had not been sending out the bed hold notice forms but would start doing so in the future. For Resident 19, who was transferred to the hospital on 4/20/2024, there was also no documented evidence of a bed hold notification being provided. The DHS confirmed that nursing staff are supposed to send the bed hold policy with a resident when going to the hospital, but this was not done in these cases.
Failure to Ensure Regular Physician Visits
Penalty
Summary
The facility failed to ensure that residents were seen by a physician at the required intervals. Specifically, four residents were not seen by a physician at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter. For instance, Resident 52, who had multiple diagnoses including paranoid schizophrenia and type 2 diabetes mellitus, had no documented physician visits for the past year. Similarly, Resident 74, who was admitted under commercial insurance and later transitioned to Medicaid, was only seen by a physician twice, with no further visits documented. The Director of Health Services and the physician both acknowledged the requirement for regular visits but failed to ensure compliance. Additionally, Resident 1, who was readmitted with acute respiratory failure and COPD, had no documented physician visits from January 2023 through May 2024. Resident 50, who had diagnoses including lack of coordination and unspecified dementia with behavior disturbances, also had no documented physician visits for the last 12 months. Interviews with staff, including the Corporate Nurse Consultant, confirmed that each resident should have an in-person physician or nurse practitioner visit every 30 days, with the physician alternating visits with the nurse practitioner every 60 days. However, this protocol was not followed, leading to the deficiency.
Failure to Maintain Proper Food Temperatures
Penalty
Summary
The facility failed to ensure all food items on the steam table were held above 135 degrees Fahrenheit to prevent bacteria growth. This deficiency affected nine residents ordered a puree consistency diet out of a total of 99 residents receiving an oral diet. During an observation, the puree beef patty was found to have a temperature of 132 degrees Fahrenheit. The Dietary Manager confirmed the temperature and acknowledged that all food items on the steam table need to be held at or above 135 degrees Fahrenheit. The Dietary Manager also noted that there had not been any previous issues with the steam table maintaining food temperatures until that meal.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to assess a resident (R71) for the ability to self-administer medications before allowing medications to be left at the bedside. The resident, who had diagnoses including schizophrenia, major depressive disorder, anemia, and chronic kidney disease, was observed with over-the-counter products (vapor rub and cough drops) on the nightstand. The resident reported that her family had brought the items for her, and she kept them in her room. However, there was no documentation in the electronic medical record indicating that R71 had been assessed for the ability to self-administer medications. During an interview, an LPN confirmed that residents could have medications at their bedside if assessed to do so, but verified that R71 had not been assessed. The LPN then removed the items from the bedside. The Director of Health Services later reported that she was unaware of the resident having over-the-counter medications in the room prior to the nurse bringing the items to her attention. This oversight had the potential to allow access to medications not prescribed by a physician to other residents, staff, or visitors.
Failure to Provide SNF ABN to Resident Discharged from Medicare Part A
Penalty
Summary
The facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to a resident who was discharged from Medicare Part A coverage. Specifically, the resident was discharged from Medicare Part A skilled services and remained in the facility with benefit days remaining. There was no documented evidence that the SNF ABN was provided to the resident or the responsible party. During an interview, the Administrator revealed that the Financial Controller was new and only familiar with Medicare Part B, and was unaware that the SNF ABN was a required notice for residents discharged from Medicare Part A skilled services who remained in the facility. The Administrator confirmed that the resident and/or the responsible party did not receive an SNF ABN.
Failure to Provide Specialized Psychiatric Services
Penalty
Summary
The facility failed to provide specialized psychiatric services for a resident with a serious mental illness (SMI) as recommended by the Preadmission Screening and Resident Review (PASRR) Level II summary. The resident, who was admitted with a diagnosis of schizophrenia and was receiving antipsychotic medication, had a care plan that included behavioral health assessment/service plan and diagnostic/ongoing psychiatric care. However, a review of the electronic medical record (EMR) revealed no documented evidence that the resident received the recommended specialized services. Observations over several days showed the resident was pleasant and exhibited no behaviors. Interviews with staff, including a registered nurse and a social worker, confirmed that the resident should have been receiving psychiatric and psychotherapy services. The social worker believed the services were already in place but was unable to locate any documentation to support this. An email communication indicated that the consent and paperwork for treatment were resent, but there was no evidence that the services had been provided up to that point.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, leading to potential gaps in their treatment and care. For one resident, who had diagnoses of dementia and anxiety, the facility did not create care plan areas for the use of antipsychotic and anti-anxiety medications, despite these medications being prescribed and administered regularly. Interviews with staff revealed that the comprehensive care plans should have included these medications, and the oversight was acknowledged by the Case Management Director and the Director of Health Services. This failure persisted despite multiple quarterly assessments and updates to the care plan, indicating a systemic issue in the care planning process. Another resident, who was on a controlled carbohydrate diet and had a lactose allergy, was not provided with meals that adhered to these dietary restrictions. Despite the care plan and meal tray ticket indicating the lactose allergy, the resident was served foods containing lactose, such as cream sauce and sherbet. The Dietary Manager confirmed this discrepancy during an observation. This failure to implement the care plan as ordered highlights a lapse in the facility's dietary management and adherence to prescribed dietary needs.
Failure to Provide Lactose-Free Diet as Ordered
Penalty
Summary
The facility failed to ensure that a resident (R77) was served a lactose-free diet as ordered by the physician. Despite the resident's meal tray ticket indicating an allergy to lactose, R77 was repeatedly served food items containing lactose. This included a cheese omelet and regular milk for breakfast, as well as country fried steak with cream sauce and sherbet for lunch. The Dietary Manager confirmed that these items contained lactose and acknowledged that the resident should not have been served these foods. Additionally, the Dietary Manager revealed that there was no facility policy regarding therapeutic diets, food allergies, or lactose intolerance. R77 had a medical history that included type 2 diabetes, hemiplegia/hemiparesis, chronic kidney disease, and moderate protein calorie malnutrition. The resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Despite the clear documentation of the lactose allergy in the electronic medical record and on the meal tray ticket, the facility's failure to adhere to the prescribed diet resulted in the resident being served inappropriate food items. This deficiency was identified through observations, resident and staff interviews, and record reviews conducted by the surveyors.
Failure to Conduct Annual GDR Assessment for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a Gradual Dose Reduction (GDR) assessment was completed at least annually for a resident (R50) who was receiving antipsychotic medication. According to the facility's policy titled Monitoring of Antipsychotics, a GDR assessment should be conducted annually after the first year of antipsychotic medication use. However, the last documented GDR for R50's haloperidol was dated 4/27/2023, and no other GDRs were completed in the last 12 months. This failure was confirmed by the Director of Health Services (DHS) during an interview, who acknowledged that the pharmacist normally conducted a GDR for antipsychotic medications at least annually and that one should have been completed for R50. R50's medical records revealed that the resident had active diagnoses of dementia and anxiety and was receiving multiple psychotropic medications, including haloperidol, Xanax, mirtazapine, and PRN lorazepam. Despite regular psychiatric evaluations and medication management, no changes were recommended by the psychiatric clinician in progress notes dated 10/23, 1/24, and 4/24. The DHS verified that the pharmacist's email dated 5/18/2024 confirmed the resident's medication regimen but did not include a recent GDR assessment for haloperidol, highlighting the facility's failure to adhere to its own policy and regulatory requirements.
Failure to Properly Store, Label, and Discard Medications
Penalty
Summary
The facility failed to ensure medications and biologicals were dated when opened, discarded on the discard dates, and stored according to manufacturer recommendations on one of three medication carts (East Unit Cart 2). Observations revealed that several medications, including insulin vials, insulin pens, ophthalmic solutions, and inhalers, were either not labeled with open and discard dates or were stored improperly. Specifically, medications such as Novolog insulin, Levemir insulin, Humalog Kwik Pen, Incruse Ellipta inhaler, Trelegy Ellipta inhaler, and Anoro Ellipta inhaler were found to be opened with expired discard dates. Additionally, unopened medications with pharmacy labels instructing refrigeration until opened were not stored in the refrigerator as required. Interviews with the LPN and the Director of Health Services (DHS) confirmed that the medications should have been labeled with open and discard dates and stored according to manufacturer and pharmacy instructions. The LPN acknowledged that medications administered past the discard date could be less effective, potentially causing altered effects for the residents. The DHS stated that all nurses working on the medication carts were responsible for ensuring proper storage, labeling, and discarding of medications, and that Unit Managers were expected to check the medication carts weekly for compliance. The failure to adhere to these protocols created the potential for residents to receive medications with altered effectiveness.
Failure to Maintain Clean Ice Scoop Bin and Beverage Dispenser
Penalty
Summary
The facility failed to ensure the ice scoop bin and beverage dispenser were free from green and black buildup on one of two units (West). Observations revealed that the ice scoop was stored in a clear container with black buildup and water along the edges. This ice scoop was used by CNAs to deliver ice to residents' rooms. Additionally, the water dispenser on the same unit had green and black buildup on the rubber parts inside the dispenser. The Dietary Manager confirmed the buildup and reported that the container was cleaned daily, but more attention to cleaning might be needed. There was no documentation of the last cleaning for the ice scoop container. Interviews with staff, including an LPN and the Director of Health Services (DHS), confirmed the presence of the buildup and the lack of a cleaning schedule for the ice scoop on the units. The DHS acknowledged the need to develop a system for regular cleaning moving forward. The facility policy titled Cleaning Procedures: Serving Equipment, last revised on 9/29/2022, was reviewed and indicated that the ice scoop and holding bin should be washed, sanitized, and air-dried daily, but this procedure was not followed as observed during the survey.
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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