Riverdale Center For Nursing And Healing
Inspection history, citations, penalties and survey trends for this long-term care facility in Riverdale, Georgia.
- Location
- 315 Upper Riverdale Road, Riverdale, Georgia 30274
- CMS Provider Number
- 115144
- Inspections on file
- 24
- Latest survey
- March 15, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Riverdale Center For Nursing And Healing during CMS and state inspections, most recent first.
Improper Labeling, Dating, and Storage of Opened Food Items: Surveyors found opened dry goods in the storage area without open dates, including grits and potato pearls, and an opened bag of egg noodles that was not properly labeled or dated. An opened, partially used container of cole slaw dressing was also stored on a shelf in the dry storage area instead of being refrigerated. The DM confirmed the items were not handled according to policy.
A resident with bradycardia, epilepsy, and vascular dementia did not receive a required annual comprehensive MDS assessment within the regulatory timeframe. Facility policy required a comprehensive assessment to be completed within a specified ARD window, but the last full comprehensive MDS for this resident was done more than a year before surveyor review. Staff interviews confirmed that the prior MDS coordinator failed to complete the assessment, despite an established process that uses an entry tracking assessment, payor-source–driven scheduling, and an MDS Clinical List to identify due assessments.
Surveyors found that MDS assessments were not accurately completed for two residents. One resident with multiple medical conditions, including epilepsy and vascular dementia, had a quarterly MDS that documented no falls, even though facility incident records and staff interviews confirmed an unwitnessed fall that led to hospital transfer. Another resident with peripheral vascular disease had an MDS indicating daily bed rail use, while observations over several days, the resident’s own statements, the care plan, and physician orders all showed that no bed rails were present or ordered. The MDS Coordinator and unit leadership acknowledged that the MDS coding for both residents was incorrect.
An LPN administered a resident’s metoprolol from another resident’s medication packet after stating the ordered medication was not available on the cart. The MARs showed the two residents had different metoprolol orders, and the Unit Manager and DON stated the medication should have been obtained from the backup medication-dispensing system or the pharmacy instead of another resident’s supply.
A resident with multiple contractures and total dependence for ADLs was not receiving restorative care even though OT discharge documentation recommended it after therapy ended. Interviews showed the therapy team did not complete the required restorative referral process, the resident was never added for discussion in morning meetings, and the ADON, CNA, and charge nurse each described gaps in communication and follow-through regarding the resident’s mobility needs.
A resident receiving hospice care had no hospice plan of care or documented communication process available in the facility record. Staff stated they relied on verbal updates from hospice, but an LPN, RN, DON, and NHA confirmed the EMR did not show hospice interventions or services and the facility had not maintained the required coordination documents. The resident had advanced cognitive impairment, was nonverbal, and was receiving hospice for senile degeneration of the brain.
Infection control failed during catheter care for a resident with a suprapubic catheter and EBP in place. An LPN did not wear a gown, placed uncleaned scissors into her pocket after cutting the dressing, and did not sanitize the bedside table after using a wash basin. The DON and IP stated gowns, table sanitizing, and cleaning scissors were expected during catheter care.
The facility's kitchen had several sanitation and safety deficiencies, including a soiled ceiling vent, an exposed electrical outlet, peeling paint, warped food trays, and a dirty eyewash sink. Interviews revealed a lack of awareness and timely action regarding these issues, indicating gaps in communication and oversight within the facility's maintenance processes.
A nonverbal resident with multiple medical conditions was found to have the call light out of reach on several occasions. Staff interviews confirmed the resident's inability to use the call light, and the care plan lacked interventions for this issue. The facility's policy requires accommodating individual needs, but no alternative alert system was in place for the resident.
A facility failed to implement a comprehensive oxygen care plan for a resident, resulting in the resident not receiving the prescribed oxygen therapy. The care plan indicated the need for oxygen due to ineffective gas exchange, but observations showed the resident with oxygen tubing on her forehead and the flow set incorrectly. Staff interviews confirmed the care plan did not reflect the physician's orders, and the DON and Administrator acknowledged the inconsistency and lack of adherence to the physician's recommendations.
The facility failed to update care plans for three residents, leading to potential care discrepancies. One resident with COPD frequently removed her prescribed continuous oxygen, which was not documented in her care plan. Another resident's care plan lacked a physician's order for continuous oxygen, and the flow was incorrectly set. A third resident's care plan was not updated after an incident of inappropriate touching, leaving her vulnerable. Staff interviews confirmed these deficiencies, and the DON acknowledged the need for accurate care plans.
A resident with severe cognitive impairment and dependent on staff for ADLs was not provided necessary grooming care, specifically shaving, despite multiple requests. Observations confirmed the resident needed a shave, and interviews with staff revealed a lack of documentation and adherence to the facility's grooming policy.
The facility failed to administer oxygen therapy according to physician orders for two residents. One resident's oxygen was not attached and set at a lower flow rate than prescribed, while another resident was observed without oxygen during an activity, despite a continuous oxygen order. Staff interviews confirmed the discrepancies and lack of adherence to care plans.
Improper Labeling, Dating, and Storage of Opened Food Items
Penalty
Summary
The facility failed to ensure that opened food items in the dry storage area were properly labeled and dated, and dietary staff also failed to ensure that an opened food item was properly refrigerated. Review of the facility policy titled Food Receiving and Storage stated that dry foods stored in bins are to be removed from original packing, labeled, and dated, and that all foods stored in the refrigerator or freezer are to be covered, labeled, and dated. During observation of the dry storage area, surveyors found a five-pound bag of grits that had been opened with no date and a three-pound box of potato pearls that had been opened with no open date. The Dietary Manager confirmed that both items lacked an open date and stated that dietary staff are to date opened or used food items before placing them in storage. Later observations in the dry storage area found a large clear resealable plastic bag containing egg noodles that had been removed from its original packaging, but the bag had no label and had a date written on it that the Dietary Manager identified as the use-by date rather than an open date. Surveyors also observed a one-gallon container of cole slaw dressing that had been opened and partially used, stored on the shelf in the dry storage area instead of being refrigerated, and it also lacked an open date. The Dietary Manager confirmed that the egg noodles were not properly labeled or dated and that the opened cole slaw dressing should have been stored in the refrigerator, not the dry storage area.
Failure to Complete Required Annual Comprehensive MDS Assessment
Penalty
Summary
The facility failed to complete a timely comprehensive Minimum Data Set (MDS) assessment for one resident, resulting in noncompliance with required assessment timeframes. Facility policy titled "MDS 3.0 Completion" stated that an annual comprehensive assessment must be completed using an Assessment Reference Date (ARD) no more than 366 days from the most recent prior comprehensive assessment and no more than 92 days from the most recent quarterly assessment. The resident’s electronic medical record showed an admission date of 02/18/2024 with diagnoses including bradycardia, epilepsy, and vascular dementia. Record review revealed that the last full comprehensive MDS assessment for this resident was completed on 01/24/2025, and no subsequent comprehensive assessment was completed within the required annual timeframe. During interviews, the MDS Coordinator II confirmed that a comprehensive assessment was not completed for this resident in February 2026, as required, and attributed the missed assessment to the previous MDS Coordinator’s failure to complete it. The Administrator stated that the MDS department should follow the Resident Assessment Instrument (RAI) Manual for guidance. The MDS Coordinator II further explained that the facility’s system for ensuring timely assessments involves completing an entry tracking assessment upon admission and then scheduling further MDS assessments based on the resident’s payor source, using the MDS Clinical List and the MDS tab to identify which assessment is due and when. Despite this system, the required annual comprehensive MDS assessment for this resident was not completed within the regulatory timeframe.
Inaccurate MDS Coding for Falls and Bed Rail Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate completion of MDS assessments for two residents. For one resident with diagnoses including bradycardia, epilepsy, and vascular dementia, the quarterly MDS dated 01/19/2026 documented no falls in Section J, despite facility incident records showing the resident sustained a substantiated unwitnessed fall on 12/06/2025, during which the resident was unresponsive, did not respond to commands, and was transported to the hospital via 911. The resident later stated he had fallen in the past and gone to the hospital once, and an LPN reported the resident had two unwitnessed falls and was sent to the hospital in December 2025 for a fall with possible seizure activity. The MDS Coordinator confirmed that the fall on 12/06/2025 should have been coded on the 01/19/2026 quarterly MDS and that Section J was not accurately completed. For another resident admitted and readmitted with diagnoses including peripheral vascular disease, the quarterly MDS dated 12/18/2025 documented a BIMS score of 15 in Section C and indicated daily use of bed rails in Section P. However, the resident’s care plan dated 12/21/2025 contained no focus area for restraint use, and the physician’s orders contained no order for restraints. Multiple observations over several days showed the resident in bed or in the room without any bed rails on the bed. The resident stated he did not have bed rails and could transfer without them. The MDS Coordinator confirmed that the MDS incorrectly documented bed rail use, and the Unit Manager stated the resident did not use bed rails, there were no physician’s orders for bed rails, and an audit of bed rail use had been provided to the MDS Coordinator for updating MDS assessments.
Medication Given From Another Resident’s Supply
Penalty
Summary
The facility failed to ensure that residents' medications were free from misappropriation by licensed nursing staff during medication administration observations. The facility's Medication Administration policy, revised 04/2025, stated that medication source should be compared with the MAR to verify the resident name, medication name, form, dose, route, and time. The MAR for one resident showed an order for metoprolol succinate ER 25 mg by mouth daily for hypertension, while another resident's MAR showed an order for metoprolol tartrate 25 mg by mouth twice daily. During medication administration observation, an LPN stated that the first resident's metoprolol ER 25 mg was not available on the medication cart and said she would obtain it from the second resident's medication packet because it was the same medication. The LPN removed the medication from the second resident's pill card and administered metoprolol tartrate 25 mg from that resident's supply to the first resident. The Unit Manager stated the LPN should not have administered medication to one resident from another resident's medication card and that the correct medication should have been obtained from the backup medication dispensing system. The DON stated that if a resident's medication was not available, the nurse should obtain it from the facility's backup medication-dispensing system, and if it was not available there, the nurse should call the pharmacy.
Failure to Provide Recommended Restorative Care
Penalty
Summary
The facility failed to ensure that one resident with contractures of the right and left hands, knees, ankles, and feet received restorative care services as recommended by therapy staff. The resident’s significant change MDS documented that the resident was dependent on staff for all ADLs. OT discharge documentation stated that restorative services were recommended after therapy discharge, but the resident was not receiving restorative care at the time of review. Interviews showed breakdowns in the facility’s process for identifying and initiating restorative services. The ADON stated she was responsible for the restorative care program and confirmed the resident was not receiving restorative care. The DT stated that therapy staff were supposed to complete a paper form when restorative services were recommended, but she could not locate the form for this resident and stated therapy staff did not follow the proper process to ensure the resident was placed on the restorative list. The ADON also stated the resident had not been discussed in morning meetings for restorative services. A CNA stated she had notified the charge nurse about the resident’s mobility issues, while the charge nurse stated she assumed the resident was receiving restorative services and did not recall being notified of the decrease in mobility.
Failure to Coordinate Hospice Care and Communication
Penalty
Summary
The facility failed to maintain communication and coordination of care with hospice for one resident receiving hospice palliative care services. The resident was admitted to the facility with multiple diagnoses including senile degeneration of the brain, vascular dementia, depression, diabetes mellitus type 2, hypertension, contractures, and a history of venous thrombosis and embolism. The resident was admitted to hospice for senile degeneration of the brain and had an MDS assessment showing a BIMS score of zero, indicating the resident was rarely or never understood and was receiving hospice care. Review of the facility’s hospice care plan showed that the resident began receiving hospice services and that facility staff were to notify hospice of significant changes, clinical complications, transfer needs, and death, while also assessing symptoms such as pain, restlessness, agitation, constipation, and other discomfort. The facility’s hospice and nursing facility services agreement also required a communication process documenting how communication between the facility and hospice provider would occur to ensure the resident’s needs were met 24 hours per day. The facility policy stated that the DON was responsible for coordinating care with hospice representatives and obtaining the most recent hospice plan of care for each resident. During observations and interviews, staff members stated they did not have a hospice care plan, hospice communication book, or documentation in the EMR showing the interventions or services hospice provided for the resident. An LPN stated the facility only had its own care plan and no hospice plan of care was available. An RN stated she could not determine what hospice did or was responsible for because there was no documentation of hospice services in the EMR. The DON confirmed there was no hospice care plan or communication book and said hospice staff only verbally reported to nursing staff. The NHA later confirmed the hospice plan of care and coordination documents were not obtained until after the issue was identified, and the DON stated she had not read the hospice policy and was not involved in care planning for residents receiving hospice services.
Infection Control Failure During Catheter Care
Penalty
Summary
The facility failed to follow its infection control process during indwelling catheter care for one resident with a suprapubic catheter. The resident was admitted and later readmitted with diagnoses including retention of urine, and the quarterly MDS documented an indwelling catheter. The care plan identified a suprapubic catheter related to neurogenic bladder, retention of urine, bilateral hydronephrosis, obstructive and reflux uropathy, and benign prostatic hypertrophy, with interventions that included cleaning the catheter stoma site as ordered and maintaining enhanced barrier precautions. During observed catheter care, the LPN did not wear a gown even though enhanced barrier precautions were in place and PPE was available in the hallway near the room. The LPN also used a pair of scissors to cut the old dressing from the catheter, placed the scissors into her uniform pocket without cleaning them, and did not clean the resident's bedside table after removing the wash basin used during the procedure. Personal items were observed on the bedside table used for the catheter care. In interview, the LPN stated she should have worn a gown because the resident was on enhanced barrier precautions and catheter care was a high-contact procedure. She also stated the bedside table should have been cleaned after the wash basin was removed and the scissors should have been cleaned before being placed in her pocket because of cross-contamination and infection concerns. The DON and Infection Preventionist both stated that gowns and gloves were expected for catheter care, that bedside tables used during the procedure should be sanitized, and that scissors should be cleaned after use rather than placed in a pocket uncleaned.
Kitchen Sanitation and Safety Deficiencies
Penalty
Summary
The facility failed to maintain a safe and sanitary kitchen environment, which posed potential safety and sanitation hazards to all 121 residents receiving an oral diet. Observations revealed several deficiencies, including a ceiling vent in the dietary hallway that was soiled with dust and debris, an exposed electrical outlet in the dishwashing room, peeling paint above the stove and oven area, and numerous metal food trays that were warped and unserviceable. Additionally, the eyewash sink was found with a visible brown substance pooled in it, covered by a tray. Interviews with the Dietary Services Manager (DSM) and the Maintenance Director (MD) indicated that the facility had an electronic work order system for repairs, but there was a lack of awareness and timely action regarding the identified issues. The DSM was unaware of the dirty vent and the missing faceplate on the electrical outlet, while the MD confirmed the need for cleaning and repairs. The Administrator also expressed unawareness of the deficiencies, highlighting a gap in communication and oversight within the facility's maintenance and sanitation processes.
Failure to Ensure Call Light Accessibility for Nonverbal Resident
Penalty
Summary
The facility failed to accommodate the needs of a resident, identified as R60, by not ensuring that the call light was within reach. Observations on multiple occasions revealed that R60, who is nonverbal and has several medical conditions including dysphagia, muscle weakness, and cerebral palsy, was lying in bed with the call light out of reach. The facility's policy on Accommodation of Needs requires that residents' individual needs and preferences be reasonably accommodated, yet R60's care plan did not include goals or interventions related to the accessibility of the call light. Interviews with staff, including an LPN and the Unit Manager, confirmed that R60 could not use the call light and that staff checks on her frequently. However, the Unit Manager acknowledged that an alternative method should be in place for R60 to alert staff in case of distress. The Administrator was unaware of R60's inability to use the call light and confirmed the need for an emergency alert system for R60, as she cannot rely on her roommate for assistance.
Failure to Implement Oxygen Care Plan for Resident
Penalty
Summary
The facility failed to implement a comprehensive oxygen care plan for a resident, identified as R60, which resulted in the resident not receiving the prescribed oxygen therapy. The care plan for R60, dated December 26, 2024, indicated that the resident required oxygen therapy due to ineffective gas exchange and had a tendency to remove the oxygen from her nose. Despite this, observations on March 17, 2025, revealed that R60 was nonverbal and lying in bed with the oxygen tubing on her forehead and the oxygen flow set at 2.5 LPM, contrary to the physician's order of 3.5 LPM. Interviews with staff, including an LPN and the Unit Manager, confirmed that the oxygen was not attached as required and that the care plan did not reflect the physician's orders. Further interviews with the Director of Nursing (DON) and the Administrator highlighted that there was no documentation in the care plan for R60's oxygen orders, and staff were not following the physician's recommendations. The DON acknowledged that the care plan, physician's orders, and oxygen flow should be consistent, and staff should visit the resident more frequently if she was known to remove her oxygen. The Administrator confirmed that all orders, including those for oxygen, should be followed according to the physician's recommendations, but this was not being done for R60.
Failure to Revise Care Plans for Residents
Penalty
Summary
The facility failed to revise care plans for three residents, leading to potential discrepancies in the care provided. For one resident with chronic respiratory failure and COPD, the care plan did not reflect the resident's behavior of removing her oxygen, which was prescribed to be worn continuously. Observations showed the resident frequently without her oxygen, and interviews with staff confirmed the lack of documentation allowing this behavior. The Director of Nursing (DON) acknowledged the inconsistency between the care plan and the physician's orders, emphasizing the need for staff to follow the prescribed orders. Another resident's care plan did not include the physician's order for continuous oxygen at 3.5 LPM. Observations revealed the resident's oxygen was not attached, and the flow was set at 2.5 LPM, contrary to the physician's order. Interviews with staff confirmed the omission of the oxygen order in the care plan and the incorrect flow setting. The Respiratory Therapist admitted to attempting to wean the resident off oxygen without documenting or consulting the physician, further contributing to the care plan's inadequacy. The third resident's care plan was not updated to address an incident of inappropriate touching, leaving the resident vulnerable. Interviews with the MDS Coordinator and Social Services Director confirmed the absence of an updated care plan to reflect the incident. The DON and Administrator acknowledged the need for the care plan to include measures addressing the resident's vulnerability following the incident.
Failure to Provide Grooming Care for Resident
Penalty
Summary
The facility failed to provide necessary grooming care for a resident, identified as R70, who was dependent on staff for assistance with activities of daily living (ADLs). R70, who had severe cognitive impairment and required assistance with ADLs, was observed on multiple occasions needing a shave, which was not provided despite his requests. Interviews with R70 revealed that he had asked for a shave several times but was told by staff that they did not have time. Observations confirmed that R70 had facial hair and needed grooming. The facility's policy on ADLs, which was revised in January 2024, mandates that residents unable to perform ADLs should receive necessary services to maintain grooming and personal hygiene. However, interviews with staff, including a Licensed Practical Nurse (LPN) and the Director of Nursing (DON), revealed that the facility did not maintain a grooming log, and there was no documentation of resident grooming. The DON confirmed that residents should not have to wait days for grooming if requested, and the Administrator acknowledged that residents' grooming requests should be honored.
Failure to Administer Oxygen Therapy as Prescribed
Penalty
Summary
The facility failed to administer oxygen therapy in accordance with physician orders for two residents, R60 and R17. R60, who was admitted with multiple diagnoses including dysphagia, muscle weakness, and shortness of breath, had a physician's order for oxygen at 3.5 liters per minute (LPM) via nasal cannula continuously. However, observations revealed that R60's oxygen was not attached, and the flow was set at 2.5 LPM instead of the prescribed 3.5 LPM. The care plan for R60 did not include goals and interventions for oxygen therapy, and the respiratory therapist attempted to wean R60 off oxygen without documenting or consulting the physician. R17, diagnosed with chronic respiratory failure with hypoxia and COPD, had a physician's order for continuous oxygen at 3 LPM via nasal cannula. Observations showed that R17 was not wearing her oxygen while participating in an activity in the dining area, contrary to the continuous oxygen order. The care plan for R17 included interventions for managing her respiratory condition, but the prescribed oxygen therapy was not adhered to during the observed period. Interviews with facility staff, including the Unit Manager, Respiratory Therapist, Director of Nursing, and Administrator, confirmed the discrepancies between the physician's orders and the actual administration of oxygen therapy. The staff acknowledged that the orders were not followed as prescribed, and the care plans did not reflect the necessary interventions for oxygen management, leading to a deficiency in providing safe and appropriate respiratory care for the residents.
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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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