River Towne Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Columbus, Georgia.
- Location
- 5131 Warm Springs Rd, Columbus, Georgia 31909
- CMS Provider Number
- 115566
- Inspections on file
- 25
- Latest survey
- April 1, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at River Towne Center during CMS and state inspections, most recent first.
Failure to Obtain Informed Consent for Psychotropic Medications: Two residents received psychotropic medications for depression disorder without documentation that the resident or representative was informed in advance of the risks, benefits, or alternative treatment. One resident had moderately impaired cognition and the other had severe cognitive impairment; EMR review found no signed informed consent for Bupropion, Effexor, Sertraline, or Trazodone. Staff interviews showed uncertainty about who was responsible for obtaining consent.
Kitchen Not Maintained in Clean and Sanitary Condition: Multiple areas of the kitchen floor were worn through, cracked, buckled, or missing grout, with standing water in several spots, and the Dietary Manager acknowledged the flooring was not a cleanable surface. The walls, clean knife storage, oven, and microwave were dirty with food spatter and grime, and dietary staff placed measuring spoons on top of the dirty microwave while preparing pureed bread.
Medication services failed to address missing ordered meds for a newly admitted resident with acute respiratory failure, hyperlipidemia, a trach, and glaucoma. The MAR showed the resident did not receive Budesonide inhalation suspension, Naloxegol, Isosorbide Dinitrate, or Latanoprost during the stay. Progress notes documented the meds were awaiting delivery and on back order, but an LPN stated she did not check the Omnicell or notify the physician for an update or substitute. The DON and Administrator described expectations for timely physician notification and checking available stock.
Late Medication Administration: A resident with anemia, post-amputation orthopedic aftercare, and muscle weakness had several scheduled meds documented well outside the allowed medication pass window, including a PPI, an ARB, and an opioid/APAP. The resident had moderately impaired cognition, the meds were available in the Omnicell, and UMs and the Administrator stated they were unaware of the late administrations and were not auditing med pass times; the facility policy required meds to be given within one hour of the prescribed time.
Surveyors found that expired food items, such as seasonings, dressings, gelatin, cabbage, and various cheeses, were not discarded as required by facility policy. The Dietary Manager and Administrator confirmed that expired food should have been removed during inventory checks.
Two residents did not have comprehensive, person-centered care plans addressing their specific needs. One resident with respiratory issues and a nebulizer order did not have interventions for shortness of breath included in the care plan, while another resident experiencing severe pain and receiving PRN pain medication had no pain management interventions documented. Both the MDS Coordinator and DON confirmed these omissions.
Two residents with significant physical and cognitive impairments did not consistently receive scheduled showers or adequate assistance with ADLs, as required by facility policy. Documentation and resident interviews revealed missed showers and inadequate hygiene support, despite staff statements that care was provided and documented.
Surveyors found that a syringe with an uncapped needle was left on top of a medication cart's biohazard container, rather than being properly disposed of, and hazardous cleaning chemicals were accessible in three residents' rooms, including items brought in by family members. Staff and leadership confirmed these items should not have been accessible to residents.
A resident admitted after neck surgery did not receive prescribed PRN narcotic pain medication due to the facility not obtaining the required hard copy prescription from the hospital and the receiving nurse failing to contact the physician for an alternative order. As a result, the resident experienced unmanaged pain overnight, despite documented complaints and an existing physician order in the record.
Surveyors found expired medications, including bisacodyl suppositories, Tylenol 325 mg, and Renavite, stored with unexpired drugs in a medication room. Staff and DON confirmed that expired medications should have been removed and set aside for pharmacy destruction, but this was not done according to facility policy.
Staff failed to properly store respiratory therapy equipment, such as nebulizer and BiPAP masks, by leaving them unbagged and unlabeled in resident rooms, contrary to infection control policy. Additionally, a resident with a PEG tube did not receive dressing changes as ordered, resulting in a soiled dressing remaining in place for several days. These lapses were confirmed by staff and the DON during interviews.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents or their representatives were informed in advance of the risks and benefits of prescribed psychotropic medications or of alternative treatment for two residents reviewed. R46 was admitted to the facility with moderately impaired cognition, as shown by a BIMS score of 9 out of 15 on the annual MDS. Her March 2026 medication summary showed physician orders for Bupropion and Effexor for depression disorder, but the EMR contained no documentation of any informed consent signed or reviewed by the resident or her representative before the psychotropic medications were administered. R61 was admitted to the facility with severe cognitive impairment, as shown by a BIMS score of 0 out of 15 on the MDS. His March 2026 medication summary showed physician orders for Sertraline and Trazodone for depression disorder, but review of the EMR documents found no informed consent documentation signed or reviewed by the resident or his representative before administration of the psychotropic medications. During interviews, the SSD, UM, DON, and Administrator each stated they were not familiar with, or did not clearly identify, who was responsible for obtaining informed consent for high-risk or psychotropic medications, and the facility policy titled Medication Therapy stated that medication decisions should include appropriate elements of the care process, including each resident's wishes, values, goals, condition, and prognosis.
Kitchen Not Maintained in Clean and Sanitary Condition
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary condition for 103 residents who consume food from the kitchen. During an observation with the Dietary Manager, multiple areas of the kitchen floor were worn through, broken, cracked, buckled, or missing grout, including areas in front of the steam table, three-pan sink, steamer, drink station, dish machine, stove, and walk-in refrigerator entrance. Several of these damaged areas were flooded with standing water, and the Dietary Manager acknowledged that the floor was not a cleanable surface and that the flooring needed repair. The piping underneath the three-pan sink was rusted through and exposed to the inside, the hood filter had broken slats, and the dry storage area had drywall debris falling onto the floor. The walls throughout the kitchen were observed to be dirty with food spatter, including behind the prep station, hand-washing sink, three-pan sink, and around the clean knife storage container. The clean knife storage unit itself was dirty with spatter and lint on the outside, top, and behind it, and the oven was dirty with grime and food spatter on the outside windows and sides. During the observation, dietary staff placed measuring spoons on top of a dirty microwave while preparing pureed bread, and the Dietary Manager later confirmed the microwave was dirty and cleaned it. The Administrator stated the facility was looking at the cost for the flooring but did not have any estimates, and also stated the hood vent needed to be replaced.
Medication Orders Not Addressed When Ordered Drugs Were Unavailable
Penalty
Summary
Facility pharmacy services failed to ensure medication irregularities were identified and addressed for a newly admitted resident with acute respiratory failure with hypoxia, hyperlipidemia, and a tracheostomy. The resident was admitted to the facility and later expired there. Physician orders included Budesonide Inhalation Suspension via trach twice daily, Naloxegol Oxalate via feeding tube daily, and Latanoprost Ophthalmic Solution for glaucoma in both eyes, along with Isosorbide Dinitrate. Review of the MAR showed the resident did not receive the ordered Budesonide Inhalation Suspension, Naloxegol Oxalate, Isosorbide Dinitrate, or Latanoprost Ophthalmic Solution during the three-day stay. Progress notes documented that the facility was awaiting delivery of the missing medications, that the medications were missing and reported to be on back order, and that the resident was assessed for shortness of breath with respiratory assessments and vital signs recorded each shift. During interview, the LPN stated she documented the medications were on back order but did not look in the Omnicell for the medications and did not call the prescribing physician regarding the unavailable medications for an update to the order or for a substitute. The Administrator stated his expectation was that nursing staff would inform the physician if medications were not available within the initial 12 hours of admission, check the Omnicell, and then notify the physician for a change to similar medications that were readily available. The facility policy stated the DON supervises medication administration and medications are administered in accordance with prescriber orders, including any required time frame.
Late Medication Administration
Penalty
Summary
The facility failed to administer medications within the prescribed time frame for one resident who had been admitted with diagnoses including anemia, encounter for orthopedic aftercare following surgical amputation, and muscle weakness. Review of the resident’s discharge MDS showed moderately impaired cognition, and the resident representative stated the resident did not think the resident received any medications for the first 24 hours. The medication administration audit showed Omeprazole DR 20 mg and Losartan Potassium 100 mg, both scheduled for 9:00 AM on 06/19/25, were documented as given at 2:33 PM that day. The audit also showed Oxycodone-Acetaminophen 5-325 mg, scheduled for 8:00 AM on 06/21/25, was documented as administered at 1:01 PM. The Omnicell inventory list showed the medications were available. Unit Managers stated medication pass allowed one hour before and one hour after the scheduled time, but they had not audited medication administration times and were unaware of late medications. The Administrator stated the same timing expectation and said the medications should have been pulled from the Omnicell, and that nobody was auditing for late medication administration. The facility policy titled Administering Medications stated medications should be administered within one hour of the prescribed time.
Expired Food Items Not Discarded in Kitchen
Penalty
Summary
The facility failed to discard expired food items as required by its Food Receiving and Storage policy. During a kitchen tour with the Dietary Manager, surveyors observed multiple expired food items, including ground allspice seasoning, ground ginger seasoning, French-style dressing packets, gelatin, cabbage, cream cheese, cottage cheese, and ricotta cheese. The Dietary Manager confirmed these findings and stated that inventory checks were conducted and expired food should be discarded. The Administrator also confirmed that kitchen staff were expected to ensure all expired food items were removed.
Failure to Develop Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, as required by their own policy and federal regulations. For one resident with diagnoses including pneumonia and COPD, documentation showed the resident experienced shortness of breath and had a physician's order for nebulizer treatments as needed. However, the resident's care plan did not include any interventions or guidance related to nebulizer use or management of shortness of breath. This omission was confirmed by both the MDS Coordinator and the Director of Nursing, who acknowledged that respiratory needs and nebulizer treatments should have been addressed in the care plan. For another resident admitted with orthopedic aftercare needs, muscle weakness, and cervical spinal stenosis, records indicated the resident experienced severe pain, received as-needed pain medication, and that pain occasionally interfered with sleep. Despite this, the resident's care plan did not address pain management or include any related interventions. The MDS Coordinator and the Director of Nursing both confirmed that the care plan should have included pain as a focus area, based on the resident's assessment and physician's orders.
Failure to Provide Scheduled Showers and ADL Assistance
Penalty
Summary
The facility failed to provide scheduled showers and adequate assistance with activities of daily living (ADLs) for two residents who were unable to perform these tasks independently. One resident, with diagnoses including type 2 diabetes, end-stage renal disease, muscle weakness, and morbid obesity, required substantial to maximum assistance with showering or bathing and was scheduled for showers on specific days. However, documentation showed missed showers, and the resident reported not receiving a bed bath or shower for about a month, particularly due to being out of the facility for dialysis on scheduled shower days. Staff interviews indicated that showers or bed baths were supposed to be provided and documented, but records did not support this. Another resident, with legal blindness, muscle weakness, glaucoma, and schizophrenia, also required assistance with showering or bathing. Documentation for this resident showed gaps in the provision of showers or baths, and the resident reported not receiving showers as scheduled. Observations confirmed the resident wore the same clothing on consecutive days. Staff interviews confirmed that showers were to be provided on certain days, with bed baths on others, but documentation and resident reports indicated this was not consistently done. Facility policy required that residents unable to perform ADLs independently receive appropriate support with hygiene, but this was not followed for the two residents identified.
Failure to Prevent Accident Hazards and Control Access to Hazardous Items
Penalty
Summary
Surveyors observed multiple instances where the facility failed to maintain an environment free from accident hazards. On one medication cart, an unpackaged syringe with an uncapped needle was found lying on top of a biohazard container, rather than being fully disposed of inside the container. This was confirmed by the RN, Unit Manager, DON, and Administrator, all of whom acknowledged that syringes and needles should be completely placed inside biohazard containers to prevent potential resident access and injury. Additionally, hazardous chemicals were found accessible in three residents' rooms. An aerosol disinfecting spray was left on a bedside table within easy reach of a resident, and a multi-purpose cleanser was found on top of a toilet tissue dispenser in another resident's bathroom, reportedly brought in by a family member. In a third instance, a container of disinfecting cleaner was located under the sink in a resident's bathroom, also brought in by family. Staff interviews confirmed that such chemicals should not be accessible to residents, and the DON and Administrator were unaware that family members had brought these items into the facility.
Failure to Provide Timely Pain Management Due to Medication Order Process Lapse
Penalty
Summary
The facility failed to provide appropriate pain management for one resident following admission from an acute care hospital. The resident, who had recently undergone neck surgery and had diagnoses including orthopedic aftercare, muscle weakness, and cervical spinal stenosis, was assessed as having pain at a level of five out of ten. The resident's Minimum Data Set indicated the use of PRN pain medication, with pain described as occasional but severe enough to interfere with sleep. A physician's order for oxycodone-acetaminophen was present in the medical record, but the medication was not administered as needed after admission. Interviews and record reviews revealed that the facility did not receive the required hard copy prescription for the narcotic pain medication from the hospital, and the receiving nurse did not contact the physician to obtain an alternative order for pain relief. As a result, the resident did not receive any pain medication during the night after admission, despite complaints of pain. The Director of Nursing confirmed that the facility's process required a hard copy prescription to access emergency medication stock, but this was not followed, and the necessary steps to ensure pain management were not taken.
Expired Medications Found Stored with Active Stock
Penalty
Summary
Surveyors observed that expired medications, including three boxes of bisacodyl suppositories, an opened container of Tylenol 325 mg, and three containers of Renavite, were stored alongside unexpired medications in one of the facility's medication storage rooms. The facility's policy requires that discontinued, outdated, or deteriorated medications be removed from storage and either returned or destroyed according to pharmacy instructions. Staff interviews confirmed that expired medications should be separated and placed in a designated box for pharmacy pick-up and destruction, but this process was not followed, resulting in expired drugs remaining accessible in the medication room. No specific residents were identified as being directly affected at the time of the survey, and no additional patient details or medical histories were provided in the report.
Failure to Store Respiratory Equipment and Perform Dressing Changes per Infection Control Policy
Penalty
Summary
The facility failed to ensure the safe handling, labeling, and storage of respiratory therapy equipment, specifically nebulizer and BiPAP masks, for multiple residents. Observations revealed that a resident with COPD, HIV, dementia, and other conditions had a nebulizer mask left unbagged and unlabeled on the nightstand on multiple occasions. Staff interviews confirmed a lack of awareness or adherence to the facility's infection control policy, which requires respiratory equipment to be stored in a protective bag marked with the date and resident's name. The Director of Nursing confirmed that the expected practice was not followed. Another resident with a history of pneumonia, chronic pulmonary edema, and tracheostomy status was observed to have a BiPAP mask left unbagged and exposed to the environment on several occasions. The resident reported that staff often allowed the mask to fall on the floor and did not store it in a protective bag. Staff interviews further confirmed that the BiPAP mask was not stored according to infection control procedures, and the DON reiterated the requirement for proper storage. Additionally, the facility failed to perform dressing changes as ordered for a resident with a PEG tube. The resident's dressing was observed to be soiled and dated several days prior, despite a physician's order for dressing changes every shift. Staff confirmed the dressing had not been changed as required, and the DON stated that daily dressing changes were expected. These findings demonstrate lapses in infection prevention and control practices related to respiratory equipment and gastrostomy site care.
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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