Riverview Health & Rehab Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Savannah, Georgia.
- Location
- 6711 Laroche Avenue, Savannah, Georgia 31406
- CMS Provider Number
- 115641
- Inspections on file
- 22
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Riverview Health & Rehab Ctr during CMS and state inspections, most recent first.
The facility failed to complete fall risk assessments after multiple resident falls and failed to keep oxygen cylinders secured. One resident with moderate cognitive impairment and fall-related diagnoses had a fall with head and shoulder pain, but no post-fall assessment was found. Another resident with severe cognitive impairment and multiple fractures had several falls with no fall assessments completed after any of them. In addition, an LPN confirmed free-standing oxygen tanks were left on the floor in a resident room and in the medication storage room, rather than secured in a holder or designated storage area.
Unsecured medication storage and expired medications were found in multiple carts and medication rooms. An LPN wound care cart and an RN medication cart were observed unlocked and unattended or out of direct sight during med pass, and staff confirmed the carts should have been locked. Surveyors also found numerous expired wound care products, oral meds, suppositories, ear drops, nicotine patches, and central supply items, along with insulin and methotrexate products missing open or expiration dates; staff acknowledged these items should have been removed or labeled.
Staff failed to follow the facility’s enhanced barrier precautions and hand hygiene policies during IV therapy, wound care, and colostomy care. An LPN provided IV care to a resident with a PICC line without wearing a gown, despite clear indications of enhanced barrier precautions. Another LPN prepared wound care supplies with improper glove use and did not change gloves or perform hand hygiene between packing wounds and applying outer dressings. During colostomy care, an LPN and a CNA did not wear required gowns, did not consistently perform hand hygiene or change gloves between dirty and clean tasks, and the CNA used wipes instead of soap and water to clean the ostomy area, contrary to facility expectations as described by supervisory staff.
A facility failed to ensure that two residents did not have unsecured medications at the bedside and failed to complete self-administration assessments. One resident with acute kidney failure, HTN, and sepsis had nystatin cream in plain view and reported using it without staff help, while another resident with dementia had eye drops, peroxide, and wound spray visible in the room and also reported self-administering the eye drops. An LPN confirmed both residents had not been assessed for independent medication self-administration, and the DON was unaware the medications were in the rooms.
Incomplete Care Planning for Oxygen Therapy and CPAP Care: The facility failed to develop or implement comprehensive person-centered care plans for two residents. One resident with severe cognitive impairment and an order for continuous O2 at 2 LPM had no oxygen therapy addressed in the care plan, and surveyors observed the concentrator set above the ordered flow rate. Another resident with OSA and a CPAP order had the mask found unclean and improperly stored on multiple observations, while staff confirmed the care plan only addressed daily cleaning.
Failure to verify PICC patency before IV antibiotic administration: An LPN cleaned a resident’s PICC lumen, flushed it with normal saline, and started ertapenem without aspirating for blood return. The LPN acknowledged the omission and said she should have checked for blood return; the DON stated that checking for blood return verifies PICC patency.
Improper Colostomy Care and Use of Inappropriate Cleaning Supplies: A resident with a colostomy, intact cognition, and diagnoses including cerebral infarction and muscle weakness received ostomy care that did not follow standards of practice. A CNA used bed wipes to clean around the stoma after running out of soap, and an LPN used alcohol wipes to remove the wafer; staff later confirmed that bed wipes and alcohol wipes should not be used for this care.
A resident with severe cognitive impairment received oxygen at a higher flow rate than ordered, with staff confirming the concentrator was set above the physician's 2 LPM order. In a separate issue, another resident's CPAP mask was repeatedly observed uncleaned and improperly stored in a basket with other items, and an LPN and the DON confirmed it was not being handled correctly.
Call Light Not Within Reach for a Dependent Resident: A resident with moderate cognitive impairment, vascular dementia, TBI, repeated falls, and normal pressure hydrocephalus was observed in bed with the call light placed in the overhead light rather than within reach. The resident stated she did not have a call light and did not call for help. The LPN II and DON stated residents should have access to a call light near them, with a push pad or touch button for those unable to press the button.
A facility failed to protect residents from abuse, including sexual abuse by a resident and physical abuse by a CNA. Staff were aware of incidents but did not take timely action to prevent further abuse. Policies on abuse prevention and reporting were not effectively implemented, and staff lacked adequate training.
The facility administration failed to protect residents from abuse, including physical and verbal abuse by staff and sexual abuse by another resident. The Director of Nursing did not conduct thorough investigations or report incidents, and the Administrator assumed the DON had reported them. This lack of action and adherence to policies led to potential harm to residents.
The facility failed to report allegations of verbal, sexual, and physical abuse to the State Survey Agency (SSA) as required by law. Two residents were sexually abused by another resident, and another resident was verbally and physically abused by a CNA. The DON, who is the facility's Abuse Coordinator, did not ensure the incidents were reported to the appropriate entity, and the Administrator did not contact law enforcement. This failure to report constitutes a serious deficiency in compliance with abuse reporting requirements.
A facility failed to investigate allegations of abuse involving two residents and a CNA. The facility's policy required thorough investigations, but this was not followed. The investigation into the resident-to-resident incident was incomplete, lacking resident statements and evidence of law enforcement reporting. Similarly, the CNA's personnel file contained a note from an LPN who witnessed abuse, but there was no evidence of reporting. Interviews revealed a lack of follow-up, with the DON admitting to not completing the required follow-up and the Administrator assuming the DON had reported the incidents.
A resident with a history of stroke and hemiplegia exhibited repeated verbal abuse and hypersexuality behaviors towards other residents. Despite having no cognitive impairment, the resident's inappropriate actions, such as entering female residents' rooms uninvited and physical contact, were not addressed with timely psychiatric services. The facility's failure to provide necessary behavioral health care led to the deficiency being identified as Immediate Jeopardy.
The facility failed to maintain the required RN coverage of at least eight consecutive hours per day, seven days a week, as revealed by Payroll-Based Journal records. On seven specific dates, there was no RN coverage, potentially affecting all 161 residents. The Administrator acknowledged the deficiency but could not explain the absence of RN staff on those days.
The facility failed to ensure proper food storage and staff hygiene practices, as dietary aides were observed without hair restraints, and food items in the walk-in cooler were not labeled with expiration dates. The Dietary Manager confirmed these oversights, which had the potential to affect 52 of the 61 residents receiving an oral diet.
Two residents in the facility were found with unauthorized and unsecured medications at their bedside, including nystatin hydrocortisone topical, Benadryl, and Desitin cream. The facility failed to obtain physician orders or complete Self-Administration Assessment Forms for these residents, as required by their policy. Staff interviews confirmed that the medications should not have been at the bedside without proper authorization.
A resident admitted with cellulitis of the buttocks was not provided a shower or bed bath since admission, as the facility failed to schedule or document hygiene preferences. Interviews with staff, including an LPN and the DON, revealed a lack of adherence to the facility's ADL policy, with no shower sheets or logs for the resident. The DON emphasized the unit manager's responsibility to ensure hygiene care is offered and documented.
Failure to complete fall assessments and secure oxygen cylinders
Penalty
Summary
The facility failed to ensure residents were free from accident hazards and that fall assessments were completed after falls for three residents reviewed. The facility policy titled Falls-Clinical Protocol stated staff would evaluate and document falls that occur in the facility and document risk factors for falling in the resident’s record. Review of records and staff interviews showed that fall risk assessments were not completed after documented falls for residents R109 and R55, despite facility staff stating that fall risk assessments are to be completed upon admission and anytime a resident has a fall. R109’s record showed a BIMS score of 10, indicating moderate cognitive impairment, with diagnoses including encephalopathy, syncope, non-Alzheimer’s dementia, and muscle weakness. The care plan identified R109 as at risk for falls related to confusion, psychotropic medication use, incontinence, hypotension, and muscle weakness. R109 had a fall on 02/27/2026, was evaluated by the on-call provider on 03/01/2026 for head and shoulder pain, and was later sent to the hospital and returned to the facility. The last fall assessment in the record was dated 12/19/2025, and the DON confirmed no fall assessment was completed for the 02/27/2026 fall. R55’s record showed diagnoses including periprosthetic fracture around the left hip prosthesis, multiple right rib fractures, acute respiratory failure with hypoxia, unspecified dementia with behavioral disturbance, and falls. The Five Day MDS showed a BIMS score of 4, indicating severe cognitive impairment. The resident had falls on 1/25/2026, 1/27/2026, 2/4/2026, 3/7/2026, and 3/15/2026, and no fall risk assessments were completed after any of those falls. In addition, R148’s room and the facility Medication Storage Room each had a free-standing oxygen cylinder tank positioned upright on the floor and not in a holder. R148’s room door was open, allowing access to the tank, and staff confirmed the tank was free-standing. An LPN stated oxygen tanks should be stored in a holder or in a designated labeled closet.
Unsecured medication storage and expired medications
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored in locked compartments and labeled in accordance with accepted professional principles. During observation, a wound care cart on Evergreen Hall was left unlocked with the keys in the lock while no staff member was near it, and a medication cart was also observed left unlocked in the hallway during medication administration, including times when the nurse could not see the cart from inside a resident room. Staff interviews confirmed that both carts were unsecured while in use and that the carts should have been locked with the keys kept by the nurse. The facility also had multiple expired or improperly dated medications and biologicals in medication carts, medication rooms, and central supply. Observations and interviews identified expired wound care products, expired oral and topical medications, expired suppositories, expired ear drops, expired nicotine patches, expired medical food, and expired central supply items. In addition, an insulin pen, an insulin lispro vial, and a methotrexate vial were found without open dates or expiration dates, and staff confirmed they did not know when they had been opened. Staff acknowledged that expired items should have been removed from carts and that nurses were responsible for checking medication storage for expired products. Interviews with nursing leadership and staff confirmed that nurses, unit managers, and central supply were responsible for keeping medication carts and rooms clean, locked, and free of expired medications. The DON stated that nurses were responsible for dating and labeling medications and confirmed that insulin and methotrexate should have open dates and expiration dates. The report documents that these storage and labeling failures were observed directly by surveyors and confirmed by staff during the survey.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During IV, Wound, and Colostomy Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically related to enhanced barrier precautions and hand hygiene for residents receiving IV therapy, wound care, and colostomy care. Facility policy on Enhanced Barrier Precautions required the use of gown and gloves for high-contact resident care activities such as device care (including central lines) and wound care. Policy on Handwashing/Hand Hygiene required hand hygiene before touching a resident, before aseptic tasks, after contact with blood or body fluids, after touching a resident or their environment, before moving from a soiled to a clean body site, and immediately after glove removal. Surveyors observed an LPN preparing and administering IV therapy to a resident with a PICC line without wearing a gown, despite the resident being on enhanced barrier precautions as indicated in the electronic medical record and by signage on the door. The LPN acknowledged awareness of the precautions and admitted she should have worn a gown. In another observation, a wound care LPN prepared a tray of wound care supplies while wearing gloves, then removed gauze, ABD pads, and a super-absorbent dressing from their packaging with ungloved hands. She then entered the resident’s room wearing a gown and gloves, packed the wounds, and did not change gloves or perform hand hygiene before applying the outer dressings. She later confirmed she had not worn gloves while preparing supplies and had not washed her hands or changed gloves after packing the wound. Additional deficiencies were identified during colostomy care for another resident under enhanced barrier precautions. An LPN confirmed he did not wear a gown while providing colostomy care, despite knowing the resident was on enhanced barrier precautions and acknowledging he should have worn a gown, mask, and gloves. He also admitted he did not change gloves or wash his hands after cleaning the colostomy site with soap and water and before cutting out the colostomy bag. A CNA involved in colostomy-related care confirmed she was not wearing a gown, could not recall the resident’s precautions, and acknowledged she should have worn a gown and gloves. She reported using wipes to clean the skin and wafer after removing the bag, stated she ran out of soap, and admitted she should not have used wipes to clean the area. Interviews with supervisory staff, including a unit manager, an LPN, and the DON, confirmed that residents with PICC lines, wounds, feeding tubes, catheters, and colostomies are under enhanced barrier precautions and that staff are required by facility policy to wear appropriate PPE and perform hand hygiene when transitioning from dirty to clean tasks.
Unauthorized Medications Left at Bedside Without Self-Administration Assessments
Penalty
Summary
The facility failed to ensure that two sampled residents, R155 and R113, did not have unauthorized, unsecured medications at the bedside and failed to complete assessments to determine whether either resident was capable of self-administering medications. R155 had diagnoses including acute kidney failure, hypertension, and sepsis, was cognitively intact with a BIMS score of 15, and was dependent to requiring partial or moderate assistance with ADLs and nonambulatory. Review of the EHR showed no order for the prescription and no completed self-administration assessment. Observations on 03/15/2026 and 03/16/2026 found nystatin cream on the bedside stand in public view, and R155 stated she was self-administering the cream without staff assistance and had had it since admission. An LPN confirmed the medication was in the room and that R155 had not been assessed for independent self-administration. R113 had diagnoses including non-traumatic acute dural hemorrhage, unspecified dementia, and chronic lymphocytic leukemia of B-cell type in remission. The resident’s quarterly MDS documented a BIMS score of 10, indicating moderate cognition and periods of cognitive impairment, and the EHR also lacked a completed self-administration assessment and an order for the prescription. Observations on 03/15/2026 and 03/16/2026 found eye drops on the bedside stand and a bottle of peroxide and wound spray on a dresser drawer stand next to the television, all visible to anyone entering the room. R113 reported self-administering the eye drops without staff assistance and having them for months. An LPN confirmed the eye drops were in the room and that R113 had not been assessed to self-administer medications independently, and the DON stated she was unaware of the medications in the residents’ possession.
Incomplete Care Planning for Oxygen Therapy and CPAP Care
Penalty
Summary
The facility failed to develop or implement a comprehensive person-centered care plan for two sampled residents, R56 and R6. The facility policy stated that the interdisciplinary team is responsible for developing care plans with measurable objectives and timetables to meet each resident’s physical, psychosocial, and functional needs. For R56, the quarterly MDS dated 12/30/2025 showed a BIMS score of 00, severe cognitive impairment, diagnoses including cerebral infarction without residual deficits, dysphagia, and muscle weakness, and that the resident received oxygen while a resident. The care plan dated 12/25/2025 did not address oxygen therapy, even though the physician order dated 8/20/2025 directed continuous oxygen at 2 LPM via NC every shift for comfort. Survey observations on 03/15/2026, 03/16/2026, and 03/17/2026 found the oxygen concentrator set between 3.5 and 4 LPM, and an LPN confirmed the setting was above the ordered 2 LPM. The RN/RAI Director and DON confirmed that oxygen therapy was not addressed in the care plan. For R6, the quarterly MDS dated 01/14/2026 showed a BIMS score of 12, moderate cognitive impairment, diagnoses including obstructive sleep apnea and cerebral infarction without residual deficits, and that the resident received a non-invasive mechanical ventilator while a resident. The physician order dated 09/5/2025 directed CPAP to be removed in the morning. Survey observations on 03/15/2026, 03/16/2026, and 03/17/2026 found the CPAP mask not bagged, not cleaned, and stored on top of toothpaste, cleaning products, and in a basket. An LPN stated the mask should have been bagged and cleaned and that night shift should have bagged and cleaned it, and the RN/RAI Director confirmed the care plan intervention was to clean the mask daily.
Failure to Verify PICC Patency Before IV Antibiotic Administration
Penalty
Summary
Professional standards of quality were not followed for a resident with a right upper arm PICC line who was receiving intravenous antibiotics. The facility policy titled Central Venous and Midline Catheter Flushing stated that the CVAD catheter should be aspirated for blood return to confirm patency before administration of medications and solutions. The resident had physician orders for ertapenem sodium 1 gram IV every 24 hours and daptomycin 700 mg IV every 24 hours, along with an order to flush the PICC line with 10 cc normal saline before and after each medication administration three times a day. During observation of medication administration, an LPN cleaned the PICC lumen, connected a 10 mL syringe of normal saline, flushed the line with 8 mL, and did not aspirate for blood return before connecting the ertapenem infusion. In interview, the LPN confirmed she did not aspirate for blood return and stated she should have done so, explaining she did not flush to the end of the syringe because there was air in it and she forgot to remove the air. The DON later stated that the nurse should verify the antibiotic order, prepare supplies, identify the patient, prime the antibiotic line, clean the PICC hub, flush, and check for blood return, and that checking for blood return verifies PICC patency.
Improper Colostomy Care and Use of Inappropriate Cleaning Supplies
Penalty
Summary
The facility failed to provide colostomy care consistent with professional standards of practice for a resident with a colostomy, cerebral infarction without residual deficits, and muscle weakness. The resident’s quarterly MDS showed a BIMS score of 15, indicating little to no cognitive impairment, and the care plan identified the resident as at risk for complications related to the colostomy with an intervention to perform colostomy care as ordered. During observation, a CNA used bed wipes to clean the skin around the stoma and, after running out of soap, continued cleaning the area with bed wipes again; blood was observed on the wipes. A LPN was also observed using alcohol wipes to remove the colostomy wafer, then cleaning the area with soap and water, sealing the bag to the wafer, applying a no-sting barrier, and applying powder to the skin before attaching the bag. Staff interviews confirmed that bed wipes should not be used to clean the site and that alcohol wipes should not be used to remove the wafer; the DON stated that CNAs should clean and empty the colostomy bag daily and remove the bag to clean the area with soap and water.
Oxygen Flow Rate Not Set as Ordered and CPAP Mask Left Uncleaned
Penalty
Summary
The facility failed to provide oxygen at the physician-ordered rate for one resident with severe cognitive impairment. The resident had diagnoses including cerebral infarction without residual deficits, dysphagia, and muscle weakness, and the MDS documented that the resident received oxygen while in the facility. The MAR showed an order for continuous oxygen at 2 LPM via nasal cannula every shift for comfort, but observations on multiple occasions showed the oxygen concentrator set between 3.5 and 4 LPM. An LPN confirmed the higher flow rate and stated she checked the oxygen level after medication pass. The UM and DON stated nurses were expected to check the oxygen flow rate at the beginning of each shift and during the shift, and to adjust it to match the physician's order. The facility also failed to ensure that another resident's CPAP mask was properly cleaned and stored. That resident had obstructive sleep apnea and cerebral infarction without residual deficits, and the care plan directed staff to clean the CPAP mask daily. The MAR showed an order for CPAP to be removed in the morning. Observations showed the CPAP mask lying unbagged on top of a toothpaste box in a basket of fruit, then on top of bottles of cleaning products, and later still uncleaned and lying on top of bottles in a basket. An LPN confirmed the mask was not clean and should have been bagged, and the DON confirmed the mask was not cleaned or stored correctly.
Call Light Not Within Reach for a Dependent Resident
Penalty
Summary
The facility failed to ensure that a call light was within reach for one of 32 sampled residents, R121. The facility policy titled Call System, Resident stated that residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation. Review of R121’s Quarterly MDS dated 03/03/2026 showed a BIMS score of 11, indicating moderate cognitive impairment, and diagnoses including vascular dementia, traumatic brain injury, repeated falls, and normal pressure hydrocephalus. The assessment also showed that R121 was dependent for activities of daily living. During observations on 03/15/2026 and 03/16/2026, R121 was found in bed lying on her right side, and the call light was observed in the overhead light rather than within the resident’s reach. During interview, R121 stated that she did not have a call light and that she did not call for help. The Unit Manager, LPN II, stated that residents should have access to a call light clipped to the bedside within reach, and that residents who could not push the button had access to a push pad. The DON stated that all residents should have a call light near them and that residents unable to press the call light would use a touch button.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from various forms of abuse, including verbal, sexual, and physical abuse. Specifically, three residents were not safeguarded from sexual abuse by another resident, while one resident was subjected to physical and verbal abuse by a CNA. The incidents involved inappropriate and non-consensual physical contact, such as kissing, and aggressive behavior towards residents who were unable to consent or defend themselves. The facility's staff, including the DON and LPNs, were aware of these incidents but failed to take appropriate and timely action to prevent further abuse. Reports of abuse were not adequately investigated, and there was a lack of follow-up on reported incidents. In some cases, staff members were instructed to downplay or ignore the incidents, and there was no evidence of immediate intervention to protect the residents involved. The facility's policies on abuse prevention and reporting were not effectively implemented, leading to a failure to maintain a safe environment for residents. Staff members did not receive adequate training on abuse prevention, and there was no evidence of in-service training following the incidents. The lack of proper oversight and response to abuse allegations contributed to the continuation of abusive behavior within the facility.
Removal Plan
- The facility failed to maintain an environment free from abuse by R64 affecting R60, R125, and R30 and one physical abuse incident affecting R30.
- Resident #64 is currently residing at the facility. Resident placed on 1:1 supervision upon report from State surveyor of other alleged incidents.
- The resident's primary care physician, representative and the facility Medical Director have been notified of the reported incidents.
- The facility has reassessed this resident for potential clinical needs per primary care physician.
- CBC, CMP, UA with C&S, PSA, TSH, RPR, and viral load have been ordered.
- The resident's care plan has been reviewed and revised.
- The facility contacted psych services requesting an onsite evaluation, however services have been refused by residents.
- Social Services reviewed status with IDT for appropriate placement.
- LTC Ombudsman has been notified.
- Law enforcement was notified of the reported abuse incidents affecting R60, R125, and R30.
- Resident R64 has discharged from facility.
- Resident #R125 is currently residing at the facility. The resident is responsible for self, has a BIMS of 15, and is capable of verbally expressing herself and reporting to staff.
- Resident #R125 has been reassessed for safety and potential physical/psychosocial outcomes based upon the incidents identified.
- The care plan has been reviewed and updated.
- A psych follow-up visit was provided.
- Resident #60 is currently residing at the facility. Resident's BIM is unable to be determined, but resident can make known nonverbal indicators of discomfort or distress through noises.
- Resident #R60 has been reassessed for safety and potential physical/psychosocial outcomes based upon the incident identified.
- The care plan has been reviewed and updated.
- The resident's representative and primary care physician were notified by facility of the reported incidents.
- The facility has referred R60 for psych services for assessment and support.
- Resident #30 is currently residing at the facility. Resident's BIM is unable to be determined, but resident can make known nonverbal indicators of discomfort or distress through noises.
- Resident #R30 has been reassessed for safety and potential physical/psychosocial outcomes based upon the incidents identified.
- The care plan has been reviewed and updated.
- The resident's representative and primary care physician were notified by facility of the reported incidents.
- The facility has referred R30 for psych services for assessment and support.
- The facility met and assessed with R60, R125 and R30's roommates for potential abuse for identification of safety concerns related to the reported incidents. No safety concerns were identified.
- The facility met with all residents that were deemed vulnerable for potential abuse for identification of safety concerns related to the reported incidents. No safety concerns were identified.
- Upon the report from the State surveyor, CNA AA has been suspended pending further investigation.
- The facility notified the Medical Director who has been involved in the removal of the Immediate Jeopardy.
- The administrator contacted an external consultant(s) to assist with policy review, education development and leadership training on abuse prevention and reporting.
- The facility administrator reviewed and made any necessary changes to the abuse prevention and abuse reporting policies and procedures.
- 132 of 150 (88%) of facility team members have been educated on abuse prevention, abuse reporting and comprehensive assessments.
- The remaining 18 team members will be educated on abuse prevention, abuse reporting and comprehensive assessments their next scheduled workday.
- 5 of 5 (100%) agency staff have been educated on abuse prevention, abuse reporting and comprehensive assessments.
- 16 of 22 (78%) contracted therapy staff have been educated on abuse prevention, abuse reporting and comprehensive assessments.
- The remaining 6 PRN contracted therapy staff will be educated on abuse prevention, abuse reporting and comprehensive assessments their next scheduled workday.
- A review and update of the facility orientation program and agency orientation program has been completed with respect to abuse prevention and abuse reporting requirements.
- The facility administration reviewed all audits related to residents vulnerable for potential abuse for identification of safety concerns.
- All corrective actions were completed.
- All immediacy of the IJ was removed.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility administration failed to provide protective oversight to ensure the highest practicable physical and psychosocial well-being of its residents. Specifically, the administration did not take appropriate action on allegations of employee-to-resident physical and verbal abuse involving a resident, and failed to protect three residents from sexual abuse by another resident. The administration's inaction included not adhering to facility policies on the prevention, reporting, and investigation of abuse allegations. The facility's Director of Nursing (DON), who is also the Abuse Coordinator, was aware of an incident involving two residents on a specific date but did not conduct a thorough investigation. The DON assumed that the staff member who reported the incident would notify the family and authorities, which did not happen. Additionally, the facility failed to investigate and report another incident of physical abuse by a Certified Nursing Assistant (CNA) towards a resident, where the CNA threw a mechanical lift pad at the resident, causing it to land on her face. The facility was unable to provide documentation of thorough investigations, follow-up interviews with staff, or additional resident interviews related to the incidents. The Administrator was aware of the incidents but assumed that the DON had reported them. The lack of follow-up and adherence to job responsibilities contributed to the failure in protecting residents from abuse, as the staff did not perform their duties as expected, leading to potential harm to residents.
Removal Plan
- The facility failed to provide oversight and supervision to ensure residents R30, R60, and R125 were protected from abuse by R64 and abuse by CNA AA to R30.
- CNA AA has been suspended pending further investigation.
- Resident R64 placed on 1:1 supervision upon report from State surveyor of other alleged incidents.
- Resident R64 has discharged from facility.
- The facility notified the Medical Director who has been involved in the removal of the Immediate Jeopardy.
- The facility had completed meeting/assessing with all residents who were deemed vulnerable for potential abuse for identification of safety concerns related to the reported incidents. No safety concerns were identified.
- The facility administration reviewed all audits related to residents' vulnerable for potential abuse for identification of safety concerns. No safety concerns were identified.
- The facility administration contacted an external consultant(s) to assist with policy review, education development and leadership training on abuse prevention and reporting.
- Education was provided to Administration from external consultant on job description.
- The facility administration notified President of Governing Board of Directors.
- The facility administration reviewed and made any necessary changes to the abuse prevention and abuse reporting policies and procedures. 132 of 150 of facility team members have been educated on abuse prevention, abuse reporting and comprehensive assessments.
- 5 of 5 (100%) agency staff (4 LPN and 1 CNA) have been educated on abuse prevention, abuse reporting and comprehensive assessments.
- 16 of 22 (78%) contracted therapy staff have been educated on abuse prevention, abuse reporting and comprehensive assessments. The remaining 6 PRN contracted therapy staff will be educated on abuse prevention, abuse reporting and comprehensive assessments of their next scheduled workday.
- A review and update of the facility orientation program and agency orientation program has been completed with respect to abuse prevention and abuse reporting requirements.
- A Performance Improvement Plan (PIP) was initiated related to abuse prevention and abuse reporting. ADHOC meeting held.
Failure to Report Abuse Incidents
Penalty
Summary
The facility failed to report allegations of verbal, sexual, and physical abuse to the State Survey Agency (SSA) as required by federal and state law. Specifically, two residents were sexually abused by another resident, and another resident was verbally and physically abused by a Certified Nursing Assistant (CNA). The facility's policy mandates that all alleged violations involving abuse must be reported immediately to the administrator and to the appropriate authorities, but this was not done in these cases. The Director of Nursing (DON), who is the facility's Abuse Coordinator, was informed of a kissing incident between two residents but failed to ensure the incident was reported to the appropriate entity. The DON admitted to not following up on the required 5-day report due to being busy and not knowing how to complete it. Additionally, there was no evidence that the staff to resident abuse by the CNA was reported to the SSA or law enforcement. The facility's Administrator was aware of the incident but did not contact law enforcement. The facility's failure to report these incidents in a timely manner and to the appropriate authorities constitutes a serious deficiency in compliance with abuse reporting requirements, potentially putting residents at risk of harm.
Removal Plan
- The facility failed to notify family and resident representatives of R30, R125, and R60 of alleged incidents of abuse. The facility failed to report incidents of abuse to law enforcement. The facility failed to report the results of the investigations for R30, R60 and R125 to the Administrator and State Survey agency of alleged incidents of abuse.
- Resident placed on 1:1 supervision upon report from State surveyor of other alleged incidents.
- The resident's primary care physician, representative and the facility Medical Director have been notified of the reported incidents.
- The facility has reassessed this resident for potential clinical needs per primary care physician. CBC, CMP, UA with C&S, PSA, TSH, RPR, and viral load have been ordered.
- The resident's care plan has been reviewed and revised.
- The facility contacted psychiatric services requesting an onsite evaluation, however services have been refused by resident.
- Social Services reviewed current status with IDT for appropriate placement.
- LTC Ombudsman has been notified.
- Law enforcement was notified of the reported abuse incidents affecting R60, R125, and R30.
- Resident #R125 has been reassessed for safety and potential physical/psychosocial outcomes based upon the incidents identified.
- The care plan has been reviewed and updated.
- A psych follow up visit was provided.
- Law enforcement was notified of the reported abuse incident.
- Resident #R60 has been reassessed for safety and potential physical/psychosocial outcomes based upon the incident identified.
- The care plan has been reviewed and updated.
- The resident's representative and primary care physician were notified by facility of the reported incidents.
- The facility has referred R60 for psych services for assessment and support.
- Law enforcement was notified of the reported abuse incident.
- Resident #R30 has been reassessed for safety and potential physical/psychosocial outcomes based upon the incidents identified.
- The care plan has been reviewed and updated.
- The resident's representative and primary care physician were notified by facility of the reported incidents.
- The facility has referred R30 for psych services for assessment and support.
- Law enforcement was notified of the reported abuse incident.
- The facility met and assessed with R60, R125 and R30's roommates for potential abuse for identification of safety concerns related to the reported incidents. No safety concerns were identified.
- The facility met with all residents that were deemed vulnerable for potential abuse for identification of safety concerns related to the reported incidents. No safety concerns identified.
- Upon the report from the State surveyor, CNA AA has been suspended pending further investigation.
- The facility notified the Medical Director who has been involved in the removal of the Immediate Jeopardy.
- The facility administrator reviewed and made any necessary changes to the abuse prevention and abuse reporting policies and procedures.
- The administrator contacted an external consultant(s) to assist with policy review, education development and leadership training on abuse prevention and reporting.
- 132 of 150 facility team members have been educated on abuse prevention, abuse reporting and comprehensive assessments. The remaining team members will be educated on abuse prevention, abuse reporting and comprehensive assessments their next scheduled workday.
- 5 of 5 agency staff have been educated on abuse prevention, abuse reporting and comprehensive assessments.
- 16 of 22 contracted therapy staff have been educated on abuse prevention, abuse reporting and comprehensive assessments. The remaining PRN contracted therapy staff will be educated on abuse prevention, abuse reporting and comprehensive assessments their next scheduled workday.
- A review and update of the facility orientation program and agency orientation program has been completed with respect to abuse prevention and abuse reporting requirements.
Failure to Investigate Abuse Allegations
Penalty
Summary
The facility failed to ensure allegations of abuse were thoroughly investigated for two residents. Specifically, the facility did not investigate allegations of resident-to-resident sexual abuse involving one resident and another resident, as well as an allegation of employee-to-resident abuse involving a CNA and a resident. The facility's policy required that all reports of abuse be promptly and thoroughly investigated, but this was not adhered to in these cases. The investigation into the incident between the two residents was incomplete, with only a copied and pasted email statement, an undated written statement from the unit manager, and two undated written statements from a staff member who did not witness the incident. There were no resident statements, no evidence that the incidents were reported to law enforcement, and no evidence that the residents were assessed for physical or psychological harm. Similarly, the employee personnel file for the CNA involved in the other incident contained a handwritten note from an LPN who witnessed the abuse, but there was no evidence of reporting these allegations to the SSA or law enforcement. Interviews with the DON and the Administrator revealed a lack of follow-up on the incidents. The DON admitted to not completing the required 5-day follow-up due to being busy and not knowing how to proceed. The Administrator was aware of the incidents but assumed the DON had reported them. This lack of communication and follow-through resulted in the facility's noncompliance with requirements of participation, which had the likelihood to cause serious harm to residents.
Removal Plan
- The facility failed to thoroughly investigate incidents of abuse.
- Resident placed on 1:1 supervision upon report from State surveyor of other alleged incidents.
- The resident's primary care physician, representative and the facility Medical Director have been notified of the reported incidents.
- The facility has reassessed this resident for potential clinical needs per primary care physician.
- CBC, CMP, UA with C&S, PSA, TSH, RPR, and viral load have been ordered.
- The resident's care plan has been reviewed and revised.
- The facility contacted psych services requesting an onsite evaluation, however services have been refused by resident.
- Social Services reviewed current status with IDT for appropriate placement.
- LTC Ombudsman has been notified.
- Law enforcement was notified of the reported abuse incident to R30, R60, and R125.
- Resident R64 has discharged from facility.
- Resident #R125 has been reassessed for safety and potential physical/psychosocial outcomes based upon the incidents identified.
- The care plan has been reviewed and updated.
- A psych follow up visit was provided.
- Law enforcement was notified of the reported abuse incident.
- Resident #R60 has been reassessed for safety and potential physical/psychosocial outcomes based upon the incident identified.
- The care plan has been reviewed and updated.
- The resident's representative and primary care physician were notified by facility of the reported incidents.
- The facility has referred R60 for psych services for assessment and support.
- Law enforcement was notified of the reported abuse incident.
- Resident #R30 has been reassessed for safety and potential physical/psychosocial outcomes based upon the incidents identified.
- The care plan has been reviewed and updated.
- The resident's representative and primary care physician were notified by facility of the reported incidents.
- The facility has referred R30 for psych services for assessment and support.
- The facility has met and assessed with R60, R125 and R30's roommates as well as residents who are deemed vulnerable for potential abuse for identification of safety concerns related to the reported incidents. No safety concerns were identified.
- The facility met with all residents that were deemed vulnerable for potential abuse for identification of safety concerns related to the reported incidents. No safety concerns were identified.
- Upon the report from the State surveyor, CNA AA has been suspended pending further investigation.
- The facility notified the Medical Director who has been involved in the removal of the Immediate Jeopardy.
- The facility administrator reviewed and made any necessary changes to the abuse prevention and abuse reporting policies and procedures.
- The administrator contacted an external consultant(s) to assist with policy review, education development and leadership training on abuse prevention and reporting.
- 132 of 150 facility team members have been educated on abuse prevention, abuse reporting and comprehensive assessments.
- The remaining team members will be educated on abuse prevention, abuse reporting and comprehensive assessments their next scheduled workday.
- 5 of 5 agency staff have been educated on abuse prevention, abuse reporting and comprehensive assessments.
- 16 of 22 contracted therapy staff have been educated on abuse prevention, abuse reporting and comprehensive assessments.
- The remaining PRN contracted therapy staff will be educated on abuse prevention, abuse reporting and comprehensive assessments their next scheduled workday.
- A review and update of the facility orientation program and agency orientation program has been completed with respect to abuse prevention and abuse reporting requirements.
- All corrective actions were completed.
- All immediacy of the IJ was removed.
Failure to Provide Behavioral Health Services for Resident with Inappropriate Behaviors
Penalty
Summary
The facility failed to provide necessary behavioral health services to a resident, identified as R64, who exhibited repeated verbal abuse and hypersexuality behaviors towards other residents. The resident was admitted with diagnoses including stroke and hemiplegia affecting the left side. Despite having a Brief Interview for Mental Status (BIMS) score indicating no cognitive impairment, the resident's behavior progress notes documented incidents of yelling, berating, and inappropriate physical contact with other residents. On multiple occasions, R64 was reported to have entered female residents' rooms uninvited, yelled, cursed, and even grabbed a resident's arm while she was sleeping. The Social Services Director had spoken to R64 about these behaviors, but the resident justified his actions by claiming he was trying to be helpful or that the residents had invited him in. The facility's Director of Nursing (DON) was notified of these incidents, but there was no evidence that psychiatric services were sought for R64 until after the survey began. Interviews with the facility's Administrator and DON revealed that they acknowledged their failure to address the situation adequately. They admitted to attempting to send R64 for psychiatric services, which the resident refused. The lack of timely intervention and failure to seek psychiatric services for R64 before the survey indicated a significant oversight in providing necessary behavioral health care and services, leading to the deficiency being identified as Immediate Jeopardy.
Removal Plan
- The facility failed to complete a comprehensive assessment to provide the necessary behavioral health care and services to R64 based upon incidents identified.
- Resident placed on 1:1 supervision upon report from State surveyor of other alleged incidents.
- The resident's primary care physician, representative and the facility Medical Director have been notified of the reported incidents.
- The facility has reassessed this resident for potential clinical needs per primary care physician.
- CBC, CMP, UA with C&S, PSA, TSH, RPR, viral load, and head CT without contrast have been ordered.
- The resident's care plan has been reviewed and revised.
- The facility contacted psych services requesting an onsite evaluation, however services have been refused by resident.
- The facility administration and social services have reviewed the need for potential alternative placement for R64. This has been reviewed with R64 and the Ombudsman. The facility will continue to seek out options for R64 placement.
- Resident R64 has been accepted and agreed to go to another SNF. Discharge date pending per other SNF.
- LTC Ombudsman has been notified. LTC Ombudsman updated.
- Law enforcement was notified of R64's reported abuse incidents and behaviors.
- Resident R64 has discharged from facility.
- The facility met with all residents that were deemed vulnerable for potential abuse for identification of safety concerns related to the reported incidents. No safety concerns were identified.
- The facility notified the Medical Director who has been involved in the removal of the Immediate Jeopardy.
- The administrator contacted an external consultant(s) to assist with policy review, education development and leadership training on comprehensive assessment related to behavioral health care and services to attain or maintain the highest practical well-being for residents.
- The facility administrator reviewed and made any necessary changes to the abuse prevention and abuse reporting and comprehensive assessment related to behavioral health care and services policies and procedures.
- 132 of 150 facility team members have been educated on abuse prevention, abuse reporting and comprehensive assessments. The remaining team members will be educated on abuse prevention, abuse reporting and comprehensive assessments their next scheduled workday.
- 5 of 5 agency staff have been educated on abuse prevention, abuse reporting and comprehensive assessments.
- 16 of 22 contracted therapy staff have been educated on abuse prevention, abuse reporting and comprehensive assessments. The remaining PRN contracted therapy staff will be educated on abuse prevention, abuse reporting and comprehensive assessments their next scheduled workday.
- A review and update of the facility orientation program and agency orientation program has been completed with respect to abuse prevention and abuse reporting requirements.
- A review and update of the facility orientation program and agency orientation program for licensed nursing and therapy staff has been completed with respect to comprehensive assessment processes related to residents behaviors and corresponding interventions for behavioral health care and services requirements.
- The facility administration reviewed all audits related to residents' vulnerable for potential abuse for identification of safety concerns. No safety concerns were identified.
- The facility has reviewed records of residents who display behaviors and corresponding documentation and assessment completion per policy.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure the required Registered Nurse (RN) coverage of at least eight consecutive hours per day, seven days per week, as mandated by their policy and federal regulations. This deficiency was identified through a review of the facility's Payroll-Based Journal (PBJ) records for the period from July 1, 2024, to September 30, 2024. The records revealed that on seven specific dates, there was no RN coverage for the required duration, which had the potential to affect all 161 residents residing in the facility. The facility's policy, revised in September 2022, clearly states that an RN must provide services for at least eight consecutive hours every 24 hours, seven days a week. During an interview with the Administrator on February 5, 2025, it was confirmed that there was an understanding of the PBJ data showing no RN hours on the specified dates. The Administrator acknowledged the expectation of having RN coverage and admitted to the absence of RN staff on those days, without providing an explanation for the deficiency. Despite the current presence of an RN providing patient care, the lack of coverage on the identified dates was verified, highlighting a significant lapse in meeting staffing requirements.
Deficiencies in Food Storage and Staff Hygiene Practices
Penalty
Summary
The facility failed to adhere to its Infection Prevention and Control Manual Dietary Department policy, resulting in deficiencies in food storage and staff hygiene practices. During an observation, it was noted that dietary aides were not wearing proper hair restraints, such as hairnets and beard guards, while in the food preparation area. Additionally, a walk-in cooler inspection revealed several metal containers with food items, including puree eggs, ground pork sausage, puree corn beef, chopped turkey sausage, and chopped ham, that were not labeled with expiration dates. The Dietary Manager acknowledged these oversights, attributing the lack of labeling to human error and confirming the absence of hair restraints and beard guards among staff. This deficiency had the potential to affect 52 of the 61 residents receiving an oral diet.
Unauthorized and Unsecured Medications at Bedside
Penalty
Summary
The facility failed to ensure that two residents, R303 and R136, did not have unauthorized and unsecured medicated treatment products at their bedside, which could potentially allow unauthorized access to these medications by residents and visitors. For R303, the facility did not have a physician's order for self-administration of medication, nor was a Self-Administration Assessment Form completed to determine the resident's capability to self-administer medication. Despite this, nystatin hydrocortisone topical was observed on R303's bedside table. Interviews with staff, including a CNA, LPN, and the Director of Nursing, confirmed that the medication should not have been at the bedside without an order for self-administration. Similarly, for R136, there was no physician's order for self-administration of medication, and a Self-Administration Assessment Form had not been completed. However, Benadryl and Desitin cream were observed on R136's bedside table. Staff interviews confirmed that these medications should not have been at the bedside without the appropriate orders. Both residents' medical records and assessments indicated that the facility did not follow its policy regarding self-administration of medication, leading to the deficiency.
Failure to Provide Hygiene Care for Resident
Penalty
Summary
The facility failed to provide appropriate hygiene care for a resident, identified as R357, who was admitted with a diagnosis of cellulitis of the buttocks. Upon review, it was found that R357 was not scheduled for shower preferences upon admission, and there was no documentation of a shower or bed bath being offered since the resident's admission. Interviews revealed that the resident had not been offered a shower or bed bath since the previous Tuesday, the day of admission. Further investigation through interviews with facility staff, including an LPN and the Director of Nursing (DON), highlighted a lack of adherence to the facility's policy on Activities of Daily Living. The LPN could not locate shower sheets for R357, and the resident was not on the shower log. The DON stated that it is the responsibility of the unit manager to ensure that a shower or bed bath is offered and preferences are documented upon admission. A CNA also confirmed that the resident was not provided a bed bath, attributing the lack of care to either the service not being offered or the resident refusing, although no refusal was documented.
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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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