Roselane Health Center By Harborview
Inspection history, citations, penalties and survey trends for this long-term care facility in Marietta, Georgia.
- Location
- 613 Roselane Street, Marietta, Georgia 30060
- CMS Provider Number
- 115660
- Inspections on file
- 21
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Roselane Health Center By Harborview during CMS and state inspections, most recent first.
Two residents were not protected from abuse when one, who had moderate cognitive impairment and required extensive ADL assistance, reported that a CNA refused to help her back to bed and twisted her arm, resulting in a skin tear and bruising in a fingerprint pattern, and another nonverbal resident with hemiplegia confirmed by nodding that a CNA had yelled at her to “shut up.” These incidents occurred despite facility policies stating that abuse, neglect, and exploitation are prohibited and that such occurrences will be analyzed to prevent recurrence and reported when there is reasonable suspicion of a crime.
Surveyors found that dietary staff, including a cook and the FSD with facial hair, repeatedly worked in the kitchen without required beard restraints during multiple observations. On several occasions, staff with beards were seen in food preparation and service areas, including while one cook leaned over a steam table to take temperatures on multiple food items, bringing his beard close to hot foods. Facility policy required all dietary staff to wear hair restraints, including beard restraints, and prohibited bare-hand contact with food, but these requirements were not followed, creating a potential for food contamination affecting all residents served.
Surveyors found that pureed foods for eight residents on puree or mechanical diets were not prepared according to the facility’s written puree guidelines and recipes. A cook prepared pureed pulled pork, carrots, and baked beans without using recipes, did not measure ingredients to achieve the required consistency, and described the target texture only as a “peanut butter consistency.” The cook also failed to perform proper hand hygiene before resuming work after retrieving supplies and between preparing different pureed items, and rinsed utensils in a sink during preparation. Policy required specific additives and methods to conserve nutritive value, flavor, and appearance, and leadership confirmed that pureed foods were expected to be prepared per recipe.
A resident who was cognitively intact, morbidly obese, incontinent, and dependent on a mechanical lift consistently received bed baths despite expressing a preference for showers. Over a two‑month period, shower documentation showed only bed baths with no refusals recorded and no evidence the resident was ever assisted with a shower. Staff interviews revealed that a CNA knew the resident was particular about who provided showers, but an RN of three years was unaware of the resident’s preference, despite facility policy and leadership expectations that resident bathing choices be honored and documented on twice‑weekly shower sheets.
The facility did not complete quarterly MDS assessments within the required 92-day timeframe for two residents. Record review showed that the interval between two quarterly MDS ARDs for a resident was 94 days, exceeding regulatory limits and the facility’s MDS 3.0 Completion policy. The RN VP of Clinical Reimbursement confirmed the assessments were late, and leadership acknowledged that assessments are expected to be completed on time to meet regulatory requirements and support timely care planning.
Surveyors identified that multiple residents did not receive or have documented bathing and ADL care according to the facility’s twice-weekly shower schedule and ADL policy. One resident, cognitively intact and dependent for bathing, reported never having a shower since admission despite being scheduled for twice-weekly showers, with records showing only one shower documented for the month. Another cognitively intact resident, fully dependent for bathing and oral hygiene, was observed with oily hair and was reported by family to have unshampooed hair and unbrushed teeth, while bath sheets lacked detail and were fewer than expected, with no refusals documented. A third cognitively intact resident with bilateral above-knee amputations, morbid obesity, heart disease, CKD, and an unstageable sacral ulcer reported inconsistent bed baths and that staff had largely stopped offering them, and review of several months of shower sheets showed far fewer entries than required, despite staff and the DON stating that every resident must be offered and have documented at least two baths per week, including refusals.
A resident with COPD, chronic respiratory failure with hypoxia, and other pulmonary and cardiac conditions was receiving oxygen therapy with orders for weekly and PRN cleaning of the oxygen concentrator filter. Over several observations, the concentrator’s external filter was noted to have gray, fuzzy debris. After the facility transitioned from using an RT to having nursing staff responsible for concentrator maintenance, an LPN reported checking concentrators but not turning the unit to inspect the filter and acknowledged it had likely been more than two weeks since the filter was checked. A CNA confirmed the dirty filter and was unsure of the cleaning schedule. The DON and Administrator stated that filters were expected to be cleaned weekly per facility policy and manufacturer guidance, but this was not done, resulting in the identified deficiency.
Two residents received antibiotic therapy for presumed UTIs without meeting McGeer criteria, despite the facility’s Antibiotic Stewardship Program requiring use of these criteria and CDC/NHSN definitions to guide treatment decisions. One resident with dementia and multiple comorbidities was given Nitrofurantoin for seven days for confusion and hallucinations with a positive urine culture, even though the facility’s checklist and stewardship binder documented that UTI criteria were not met. Another resident with an indwelling catheter and multiple diagnoses was treated with Ciprofloxacin for five days based on cloudy, foul-smelling urine with sediment, while the McGeer checklist and stewardship documentation again indicated UTI criteria were not met. The DON and an NP acknowledged that stewardship practices, including antibiotic time-outs and accurate tracking, were not being properly followed, and leadership confirmed that provider prescribing did not align with the facility’s established protocol.
Surveyors identified a 24% medication error rate when an LPN crushed and mixed multiple medications together for administration through a GT for a resident, contrary to professional standards, and omitted a scheduled Coreg dose without contacting the pharmacy or checking emergency stock. Review of MARs showed multiple missing documentation entries for three residents, including anticoagulants, analgesics, inhalation treatments, GI medications, topical antifungals, enteral feedings, and related blood pressure checks. The DON acknowledged that mixing crushed medications for GT administration was a deficient practice and confirmed the missing MAR documentation, while the Administrator stated that medications must be administered per policy and professional standards.
The facility failed to follow its Antibiotic Stewardship Program and McGeer criteria when initiating antibiotics for two residents. One resident with dementia, delirium, urinary retention, and other comorbidities was started on nitrofurantoin for a presumed UTI based on confusion, hallucinations, and a positive urine test, even though the McGeer checklist and stewardship documentation showed UTI criteria were not met. Another resident with an indwelling catheter and multiple medical conditions received ciprofloxacin for a UTI after staff noted cloudy, foul-smelling urine with sediment, despite the McGeer checklist and stewardship records indicating UTI criteria were not met. The DON, NP, Administrator, and National Director of Risk Management acknowledged that antibiotics were prescribed and administered without meeting McGeer criteria and that key stewardship practices, including accurate tracking and antibiotic time-outs, were not being properly implemented.
The facility failed to label, date, and ensure food items in storage were not expired, as per their policy. Observations revealed unlabeled and expired items in the freezer, refrigerator, and dry storage. The DM acknowledged these oversights, and the Administrator emphasized the expectation for compliance with food safety protocols.
The facility failed to properly dispose of garbage for two out of three dumpsters, potentially allowing pests and rodents to enter. Observations revealed trash on the ground near the first dumpster, an open side door on dumpster one, and a missing drain plug on dumpster two. The Dietary Manager was unaware of these issues, acknowledging the risk of pest intrusion.
The facility failed to ensure accurate MDS assessments for three residents, leading to incorrect coding of medications and therapy sessions. One resident's Ozempic was coded as insulin, another's therapy days were underreported, and a third's trazodone and Ozempic were misclassified. These errors resulted in inaccurate representations of the residents' health status.
A facility failed to update the PASARR for a resident diagnosed with major depressive disorder. The resident's PASARR Level I Assessment did not reflect this diagnosis, despite a psychiatric evaluation confirming it. The facility's policy requires PASARR updates for diagnosis changes, but this was not done, potentially impacting the resident's psychosocial well-being.
The facility failed to develop comprehensive care plans for two residents, leading to potential unmet care needs. One resident's care plan lacked instructions to notify the physician if insulin was not administered, while another resident's plan was incomplete regarding assistance with ADLs. Interviews confirmed the need for more specific care plans to ensure proper care.
A resident with a history of metabolic encephalopathy and end-stage renal disease experienced altered mental status and refused dialysis. Despite the facility's policy requiring notification of significant condition changes, the resident was sent to dialysis without proper communication or documentation. Upon arrival, the resident was unresponsive, leading to an emergency room transfer. Interviews revealed communication lapses among staff, contributing to the deficiency.
The facility failed to ensure narcotics were signed out before administration for a resident. An LPN obtained pregabalin oxycodone from the controlled substance lock box without verifying the count or signing it out, stating she signs out medications after administration in case of refusal. Another LPN exhibited similar behavior. The DON stated that the expectation is to verify and sign out medications at the time of administration.
A resident with Type 2 Diabetes Mellitus did not receive physician-ordered insulin on multiple occasions, and blood sugar levels were not monitored as required. The facility failed to notify the physician of these lapses. Interviews revealed that the facility occasionally ran out of insulin due to inadequate ordering practices, posing a risk to the resident's health.
A facility failed to properly clean a glucometer after use on a diabetic resident. An LPN used an alcohol wipe instead of the required germicidal wipes, which were not available on the medication cart. The resident was receiving insulin treatment for type two diabetes mellitus. The Unit Manager confirmed the correct procedure, and the DON acknowledged the incident, emphasizing the need for proper supplies on medication carts.
Failure to Protect Residents From Physical and Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse, resulting in physical harm to one resident and verbal abuse of another. One resident with acute embolism and thrombosis of the right femoral vein, history of pulmonary embolism, fibromyalgia, major depressive disorder, and dementia with agitation had a quarterly MDS showing moderate cognitive impairment and dependence on staff for transfers and significant ADL assistance. Facility documents show that this resident reported asking a CNA for assistance back to bed, and the CNA told her she could put herself in bed and then twisted her arm. A head-to-toe assessment identified a skin tear on the right arm where the resident reported the CNA twisted her arm, and a subsequent skin assessment documented bruising in a fingerprint pattern around the skin tear. During multiple later observations and attempted interviews, the resident either did not answer questions about the incident or refused to discuss it. The deficiency also includes an incident of verbal abuse toward another resident who had been admitted with essential hypertension, GERD, asthma, and hemiplegia/hemiparesis following a cerebral infarction affecting the right dominant side. The Social Worker District Coordinator reported being informed by staff that a CNA yelled at this resident to “shut up.” The SDC interviewed the resident, who is nonverbal, and the resident confirmed the allegation by nodding yes. The Administrator was notified and also interviewed the resident, who again confirmed the verbal abuse allegation by nodding. The facility’s written policies on Abuse, Neglect and Exploitation and on Reporting Reasonable Suspicion of a Crime state that the facility will prohibit and prevent abuse, neglect, and exploitation of residents and will analyze occurrences to determine why abuse occurred and what changes are needed to prevent further occurrences, as well as report any reasonable suspicion of a crime against a resident.
Failure to Enforce Beard Restraints for Dietary Staff
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to failure to ensure kitchen staff wore appropriate beard restraints in accordance with professional standards and facility policy. During an initial kitchen tour on 2/15/2026 at 11:39 a.m., a cook and the Food Service Director (FSD) were observed to have facial hair without beard nets. On 2/16/2026 at 10:49 a.m., during a comprehensive kitchen tour, another cook and the FSD were again observed with facial hair and no beard nets. Later that day at 12:05 p.m., during a food temperature observation, both cooks and the FSD were observed not wearing beard restraints while one cook took temperature readings for fifteen food items, leaning over the steam table so that his beard came into proximity to hot foods. The facility’s written policy on Dietary Employee Personal Hygiene, revised 9/1/2025, stated that all dietary staff must wear hair restraints, including beard restraints, to prevent hair from contacting food, and that employees should never use bare hand contact with any foods. The facility had a census of 127 residents at the time of the survey, and the surveyors determined that the failure to use beard nets had the potential to contaminate food and cause food-borne illnesses.
Failure to Follow Puree Food Preparation Guidelines and Recipes
Penalty
Summary
Surveyors identified a deficiency in the facility’s preparation of pureed foods for eight residents on puree or mechanical diets. The facility’s policy and guidelines for Puree Food Preparation required that pureed foods be prepared in a manner that conserves nutritive value, palatable flavor, and attractive appearance, and specified the type and amount of ingredients to be added to different food categories (such as broth or gravy for meats and poultry, margarine for noodles and root vegetables, mashed potato flakes for certain vegetables, and thickener for most fruits). During review, it was noted that the policy had been updated, and the Administrator stated that pureed foods should be prepared in accordance with recipes to present food integrity and nutritive value. During an observed puree food preparation session, a cook with five months’ tenure at the facility and five years’ experience as a cook prepared three pureed items: pulled pork, carrots, and baked beans, for eight residents receiving pureed diets. The cook did not have all supplies ready before starting, stopped production to retrieve beef base, and failed to perform hand hygiene before resuming preparation and between preparation of each pureed item. He used a sink to rinse utensils during the process, did not use a recipe, and did not measure ingredients to ensure appropriate consistency. When asked about the expected consistency, he described it as a “peanut butter consistency” and acknowledged he did not know where the recipes were located, while the Food Service Director clarified that recipe books were stored on a shelving unit near the puree preparation area.
Failure to Honor Resident Choice for Showering Versus Bed Bath
Penalty
Summary
The facility failed to honor a cognitively intact resident’s right to choose their preferred method of personal hygiene, specifically bathing versus showering. During an observation and interview, a malodorous smell was noted in the resident’s room, and the resident reported that he is always given a bed bath because he requires a mechanical lift, but that he would prefer a shower. In a follow-up interview, the resident reiterated his preference for showers but stated he felt it was too much work for staff, so he did not insist. Review of the EMR showed the resident was admitted with morbid obesity, systolic heart failure, atrophic skin disorder, xerosis cutis, bipolar disorder, and major depressive disorder, and the most recent MDS reflected a BIMS score of 14, indicating he was cognitively intact, required two staff for care, used a mechanical lift for transfers, and was incontinent of bowel and bladder. Record review of shower sheets for December and January showed only five entries in December and three in January, all documented as bed baths, with no documentation of refusals and no indication that the resident was ever assisted with a shower. Staff interviews revealed that a CNA stated the resident is particular about who showers him and that this usually occurs on second shift, while an RN who had worked at the facility for three years was unaware that the resident preferred showers over bed baths. The RN described the facility’s process that CNAs should document refusals on shower sheets and notify the charge nurse, who then confirms refusals and signs the sheet. The DON and Administrator both stated that residents should have two shower sheets per week documenting type of bath, refusals, and skin issues, and that resident choice and accommodations for those choices are expected. The facility’s Residents’ Rights policy stated that residents have the right to choose schedules and health care, including aspects of life in the facility that are significant to them, but this was not implemented for this resident’s bathing preference.
Failure to Complete Quarterly MDS Assessments Within Required Timeframe
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed within the required regulatory timeframe for two of three sampled residents. For one resident, the Electronic Health Record showed an admission date followed by a series of MDS assessments with Assessment Reference Dates (ARDs) including quarterly and annual assessments. Review of these ARDs revealed that the interval between the quarterly assessment dated 12/21/2024 and the subsequent quarterly assessment dated 3/25/2025 was 94 days, which exceeded the 92-day regulatory limit for OBRA-required assessments. This delay meant the quarterly assessment was not completed within the timeframe specified by regulation and the facility’s own policy. During interviews, the RN Vice President of Clinical Reimbursement confirmed that the quarterly assessments were late by two days, acknowledging there were 94 days between the ARDs instead of the required maximum of 92 days. The Administrator and the National Director of Risk Management stated that the facility’s expectation is that assessments are completed on time and referenced the potential negative outcomes of failing to meet regulatory requirements and ensuring appropriate care planning within required timeframes. Review of the facility’s policy titled “MDS 3.0 Completion” showed that annual assessments must use an ARD no more than 366 days from the most recent comprehensive assessment and no more than 92 days from the most recent quarterly assessment, and that quarterly assessments must use an ARD no more than 92 days from the most recent prior quarterly or comprehensive assessment, confirming that the 94-day interval was out of compliance.
Failure to Provide and Document Scheduled Bathing and ADL Care
Penalty
Summary
The deficiency involves the facility’s failure to provide and document bathing and ADL care according to residents’ needs and the facility’s own shower schedule and policy. One resident, R15, reported during an interview that she had not received a shower since admission, although she had received bed baths and preferred showers. Her admission MDS showed she was cognitively intact, dependent for bathing, and had impaired lower extremity mobility, with a care plan indicating she required assistance of two staff for bath/shower and transfers, and noted a preference for bed baths. The bath schedule assigned her room showers twice weekly on the evening shift, but review of February bath sheets showed only one shower documented out of four scheduled dates, and no bath sheet for a specific scheduled date, while she stated that staff did not ask her about taking a shower when a new roommate was offered one. A second resident, R46, also did not receive showers and related ADL care as scheduled and documented. She was cognitively intact, dependent on staff for oral hygiene, toileting hygiene, and showering/bathing, with a care plan identifying ADL self-care deficits and requiring two staff for bathing/showering, including provision of sponge baths if a full bath or shower could not be tolerated. Observation found her in bed with oily hair, and she stated she had not had a shower. Her family representative reported that her hair appeared never shampooed and her teeth appeared caked with debris, and that leadership, including the DON and Social Worker Director, had been informed. The bath schedule assigned her room showers twice weekly on day shift, but February bath sheets only showed dates without indicating what type of bathing was provided, and an LPN confirmed that only two shower sheets were present when six should have been, with no documentation of refusals. A third resident, R125, similarly did not receive or have documented twice-weekly bathing as required. He was cognitively intact with multiple significant diagnoses, including bilateral above-knee amputations, morbid obesity, heart disease, chronic kidney disease, and an unstageable sacral pressure ulcer, and was dependent on staff for oral hygiene, toileting, showers, dressing, and personal hygiene. Review of shower sheets over three months showed very few bath sheets compared to the expected number based on a twice-weekly schedule. During observation and interview, there was a very strong body odor noted, and both he and his roommate reported that baths were not provided consistently and less than twice weekly; he stated he only takes bed baths due to orthostatic hypotension and feeling unsafe sitting up, that he occasionally refuses when not feeling well, and that staff had stopped offering baths regularly. Staff interviews with a CNA, an LPN, and the DON confirmed that all residents are scheduled for two baths per week, that a bath/shower sheet should be completed for every scheduled bath including refusals, and that this documentation was not present for R125, indicating that required offers and/or provision of bathing were not consistently carried out or recorded for these residents.
Failure to Maintain Clean Oxygen Concentrator Filter for Resident on Oxygen Therapy
Penalty
Summary
The deficiency involves the facility’s failure to maintain a clean oxygen concentrator filter for a resident receiving oxygen therapy. The resident had diagnoses including COPD, chronic respiratory failure with hypoxia, interstitial pulmonary disease, and paroxysmal atrial fibrillation, and the MDS documented ongoing oxygen therapy. Physician orders directed that the oxygen concentrator filter be cleaned once weekly and as needed, and the resident’s care plan included oxygen therapy with monitoring for signs and symptoms of acute respiratory insufficiency. Multiple observations over several days showed the oxygen concentrator filter contained gray, fuzzy debris. Staff interviews revealed that responsibility for concentrator maintenance had recently shifted from a respiratory therapist, who previously checked concentrators twice weekly, to nursing staff, who were expected to clean filters weekly. A CNA stated that another nurse specialized in oxygen concentrators and changed them but was unsure of the schedule, and confirmed the presence of gray, fuzzy debris on the filter. An LPN-Unit Manager reported checking concentrators on a prior date but acknowledged not turning the concentrator around to inspect the filter and stated it had likely been over two weeks since the filter had been checked. The DON confirmed there was no respiratory therapist currently and that external filters were expected to be cleaned weekly, and the Administrator stated that concentrators were expected to be cleaned weekly, monitored, and audited. The facility’s Oxygen Administration policy required following manufacturer recommendations for cleaning equipment filters and providing care of equipment in accordance with facility policies, which was not followed in this instance.
Failure to Follow Antibiotic Stewardship and McGeer Criteria for UTI Treatment
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ drug regimens were free from unnecessary antibiotics, contrary to its Antibiotic Stewardship Program policy and use of McGeer criteria. For one resident (R92) with vascular dementia, delirium, urinary retention, cerebrovascular disease, metabolic encephalopathy, and major depressive disorder, a urinalysis with culture and sensitivity was ordered due to increased confusion and hallucinations. The practitioner documented a positive urinary tract infection (UTI) and ordered Nitrofurantoin 100 mg by mouth twice daily for seven days, which was administered from 1/13/2026 through 1/19/2026. However, the facility’s Antibiotic Stewardship Binder and the revised McGeer Criteria for Infection Surveillance Checklist dated 1/8/2026 documented that UTI criteria were not met, and that the resident did not meet McGeer criteria for antibiotic initiation. For another resident (R10) with an indwelling catheter and diagnoses including infection and inflammatory reaction due to an indwelling urethral catheter, neuromuscular bladder dysfunction, urinary retention, acute cystitis without hematuria, Type 2 diabetes with hyperglycemia, unspecified psychosis, and recurrent major depressive disorder, staff documented cloudy, foul-smelling urine with sediment and notified the practitioner with a request for urine testing. The practitioner subsequently ordered Ciprofloxacin 250 mg by mouth every 12 hours for five days for a UTI, and the medication was administered from 1/20/2026 through 1/26/2026. The revised McGeer Criteria checklist for this resident, dated 1/13/2026, documented foul smell, cloudy urine, and sediments but indicated that UTI criteria were not met, and the Antibiotic Stewardship Binder recorded that McGeer criteria for antibiotic initiation were not met. Interviews with the DON and NP II confirmed that antibiotics were prescribed and administered based on the clinical picture and positive urine culture results rather than adherence to McGeer criteria and the facility’s stewardship policy. The DON acknowledged that the facility had not been appropriately following antibiotic stewardship practices, had not been conducting antibiotic time-outs, and that the stewardship data tracking tool had not been properly implemented, resulting in inaccurate antibiotic stewardship data. The Administrator and National Director of Risk Management stated that providers were expected to follow McGeer criteria and acknowledged that the prescribing patterns in these cases did not meet the facility’s protocol.
High Medication Error Rate and Improper GT Medication Administration with Missing MAR Documentation
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5 percent, with surveyors identifying a 24 percent error rate based on 25 medication observations. During a medication pass, an LPN administered medications via a gastrostomy tube (GT) to a resident by crushing multiple medications together in one envelope, mixing them in water, and giving them through the GT, contrary to professional standards that require medications to be crushed and administered separately. In the same observation, a scheduled dose of Coreg 6.25 mg was omitted because it was not available on the medication cart, and the LPN did not contact the pharmacy or check emergency stock for the medication. The LPN later stated she had limited experience with GT medication administration, had been informally shown the process by another LPN, and was unaware of the proper method and potential harm of the practice. In addition, review of the electronic medical record and MARs revealed multiple instances of missing medication administration documentation for three residents on specific dates. For one resident, there was missing documentation for enoxaparin, diazepam, Micatin cream, albuterol inhalation solution, and oxycodone at various scheduled times. For another resident with a GT, there were missing entries for blood pressure checks and administration of amlodipine, Coreg, clonidine patch, MiraLax, Nexium, vitamin B1, amantadine, enteral feedings, and a change of feeding syringe on the night shift. A third resident’s MAR showed missing documentation for Protonix, methocarbamol, acetaminophen, and oxycodone at scheduled early morning times. The DON confirmed that mixing crushed medications for GT administration was a deficient practice and acknowledged the missing MAR documentation for the three residents, and the Administrator stated that medications should be given per policy and professional standards.
Failure to Follow McGeer Criteria in Antibiotic Stewardship
Penalty
Summary
The facility failed to implement an effective Antibiotic Stewardship Program as required by its policy and nationally recognized infection surveillance criteria, specifically the McGeer criteria, when initiating antibiotics for two residents. For one resident, R92, who had vascular dementia with psychotic disturbance, delirium due to a known physiological condition, urinary retention, cerebrovascular disease, metabolic encephalopathy, and major depressive disorder, a urinalysis with culture and sensitivity was ordered due to increased confusion and hallucinations. The practitioner documented that the urinalysis was positive for a urinary tract infection and ordered Nitrofurantoin 100 mg twice daily for seven days, which was administered as ordered. However, the facility’s Antibiotic Stewardship Binder documented that R92 did not meet McGeer criteria for antibiotic initiation. The Revised McGeer Criteria for Infection Surveillance Checklist dated 1/8/2026 for this resident recorded increased confusion and visual hallucinations, and specifically indicated that urinary tract infection criteria were not met. Despite this, antibiotic therapy was started and completed. This showed that the decision to treat was made and carried out without adherence to the established McGeer criteria that the facility’s policy required for determining when to initiate antibiotics. For another resident, R10, who had an indwelling urethral catheter and diagnoses including infection and inflammatory reaction due to an indwelling catheter, neuromuscular dysfunction of the bladder, urinary retention, acute cystitis without hematuria, Type 2 diabetes mellitus with hyperglycemia, unspecified psychosis, and recurrent major depressive disorder, staff documented cloudy, foul-smelling urine with sediment and notified the practitioner with a request for urine testing. The practitioner ordered Ciprofloxacin 250 mg every 12 hours for five days for a urinary tract infection, and the medication was administered as ordered. The Revised McGeer Criteria Checklist for this resident documented foul smell, cloudy urine, and sediments, and indicated that urinary tract infection criteria were not met. The Antibiotic Stewardship Binder also documented that this resident did not meet McGeer criteria for antibiotic initiation. Interviews with the DON, NP, Administrator, and National Director of Risk Management confirmed that antibiotics were prescribed and administered when McGeer criteria were not met and that antibiotic stewardship practices, including antibiotic time-outs and accurate data tracking, were not being properly followed per facility policy.
Failure to Label and Date Food Items in Storage
Penalty
Summary
The facility failed to ensure that all food items in the freezer, refrigerator, and dry storage were properly labeled, dated, and not expired, as per their policy titled 'Date Marking for Food Safety.' During an observation, it was found that the walk-in freezer contained a bag of turkey and a bag of hot dogs, both opened without a use-by-date. Additionally, the walk-in refrigerator had a bag of pork with an expired date, and the dry storage room contained two bowls of cereal and a bag of cake mix, all without labeling or dating. An opened bag of Jell-O was also found with an expired date. The Dietary Manager (DM) acknowledged these oversights during an interview, admitting that these items should have been caught. The facility's policy requires the head cook or designee to check the refrigerator daily for expiring food items and discard them accordingly, with the dietary manager or designee conducting weekly spot checks for compliance. The Administrator expressed that the expectation is for all kitchen items to be labeled, dated, and not expired, indicating a lapse in adherence to the established food safety protocols.
Improper Garbage Disposal in Facility Dumpsters
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse for two out of three dumpsters, which could potentially allow pests and rodents to enter. During an observation of the dumpster area behind the kitchen, it was noted that a small amount of trash was on the ground near the first dumpster. Additionally, the side door of dumpster number one was open, and dumpster number two was missing a drain plug, leaving an opening. During an interview, the Dietary Manager admitted to being unaware of the missing plug and the open door, acknowledging the risk of pest intrusion.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for three residents, leading to discrepancies in their recorded health status. For one resident, Ozempic was incorrectly coded as insulin, despite the resident's diabetes being controlled by diet and having no orders for insulin. Another resident's therapy sessions were inaccurately recorded, with the MDS indicating only one day of occupational and physical therapy, while the resident actually received six and five days, respectively, during the observation period. The MDS Coordinator acknowledged the error, attributing it to a failure to update the system daily. Additionally, a third resident's MDS inaccurately coded trazodone as an antianxiety medication and Ozempic as insulin. The resident had orders for trazodone for generalized anxiety disorder and Ozempic for severe morbid obesity. The MDS Coordinator explained that the trazodone was used for anxiety, and Ozempic was an antidiabetic medication, indicating a misunderstanding in the coding process. These inaccuracies in the MDS assessments did not accurately reflect the residents' health status during the specified observation periods.
Failure to Update PASARR for Resident with Major Depressive Disorder
Penalty
Summary
The facility failed to ensure that a resident, identified as R70, had an updated Level I Preadmission Screening and Resident Review (PASARR) following a new diagnosis of major depressive disorder. The facility's policy requires coordination with the PASARR program to ensure residents with mental disorders receive appropriate care. However, R70's PASARR Level I Assessment did not reflect the diagnosis of major depressive disorder, despite the psychiatric evaluation confirming this diagnosis. R70 was admitted to the facility with a diagnosis that included major depressive disorder, but the quarterly Minimum Data Set (MDS) assessment did not identify this diagnosis. The Social Services Director and the Administrator acknowledged that the PASARR should have been updated following the diagnosis change. This oversight has the potential to negatively impact R70's psychosocial well-being by not providing the necessary treatment for major depressive disorder.
Incomplete Care Plans for Two Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, R65 and R97, which led to potential unmet care needs. For R65, who was diagnosed with quadriplegia and type two diabetes mellitus, the care plan did not include instructions to notify the physician if the resident did not receive their prescribed insulin or if blood sugar levels were not obtained. Despite the resident being cognitively intact and receiving insulin regularly, the facility's records showed that the physician was not notified when the medication was not administered. Interviews with the Staff Development Coordinator and the Director of Nursing confirmed that the physician should have been notified and that this should have been included in the care plan. For R97, who was admitted with a stroke and osteoarthritis, the care plan was incomplete regarding the resident's needs for assistance with activities of daily living (ADLs). Although the resident was cognitively intact and required substantial assistance with ADLs, the care plan lacked specific details about the assistance needed for toileting, transfers, and the number of staff required for assistance. The MDS Coordinator indicated that the person responsible for developing the care plan was no longer with the facility, and the Director of Nursing acknowledged that the care plan needed to be more specific to ensure staff were aware of the resident's needs.
Failure to Transfer Resident with Altered Mental Status to Hospital
Penalty
Summary
The facility failed to identify a resident's need to transfer to the hospital after a change in condition, specifically altered mental status, for one of the residents reviewed. The facility's policy requires notifying the attending physician or physician on call when there is a significant change in a resident's condition, which includes the need to transfer to a hospital. However, this protocol was not followed for the resident in question, who had a history of metabolic encephalopathy, chronic pain, end-stage renal disease, and dependence on hemodialysis. The resident, who had been readmitted from the hospital with altered mental status, refused dialysis due to not feeling well. Despite being alert and talkative during a follow-up visit, the resident continued to experience pain and refused dialysis. The facility's records indicated that the resident's condition was monitored, but there was a lack of communication and documentation regarding the resident's declining condition and the need for hospital transfer. The resident was eventually sent to dialysis, where they arrived unresponsive, prompting the dialysis center to refuse responsibility and the facility to direct the transport to take the resident to the emergency room. Interviews with facility staff, including the Unit Manager, Nurse Practitioner, and Director of Nursing, revealed inconsistencies in communication and awareness of the resident's condition. The Unit Manager admitted there was likely no note communicating the resident's condition to the dialysis center, and the Nurse Practitioner did not recall being aware of the resident's decline. The Medical Director was also not informed of the resident's condition changes, highlighting a breakdown in communication and adherence to the facility's policy for managing significant changes in a resident's condition.
Failure to Sign Out Narcotics Before Administration
Penalty
Summary
The facility failed to ensure that narcotics were signed out for one of the 36 sampled residents, specifically Resident 99. During a medication administration observation, an LPN obtained pregabalin oxycodone from the locked controlled substance lock box and placed it in a medication cup with the resident's other scheduled medications. The LPN did not verify the remaining amount of pregabalin on the medication card against the controlled substance book or sign the medications out prior to administering them. The LPN stated that she administers the medications first and signs them out afterward to allow for the possibility of the resident refusing the medication, which would then be destroyed. A similar observation was made with another LPN who removed pregabalin, oxycodone, and trazadone from the controlled substance lock box without signing them out or verifying the count. The LPN also stated that she administers the medications first and signs them out afterward. The Director of Nursing (DON) stated that the expectation is for nurses to verify the medication against the MAR and label, and to sign the narcotic book at the same time as administering the medication, which is a standard of nursing practice.
Failure to Administer Insulin to Resident
Penalty
Summary
The facility failed to administer physician-ordered insulin to a resident, identified as R65, who was dependent on insulin for managing Type 2 Diabetes Mellitus. The resident's electronic medical record (EMR) indicated that insulin was not administered on multiple occasions, specifically on 10/04/24, 10/09/24, 10/22/24, 10/26/24, 10/28/24, 11/13/24, 11/15/24, and 11/30/24. Additionally, the resident's blood sugar levels were not obtained as required, and the physician was not notified of these lapses in medication administration. R65's care plan, which was intended to manage diabetes and prevent complications, did not include instructions to notify the physician if insulin was not administered or if blood sugar levels were not monitored. The resident was cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 15 out of 15, and had been receiving insulin consistently prior to the noted deficiencies. Despite the care plan's goal to prevent diabetes-related complications, the facility's failure to administer insulin and monitor blood sugar levels posed a risk to the resident's health. Interviews with the resident and facility staff revealed that the facility occasionally ran out of insulin due to inadequate ordering practices. The resident expressed concerns about the facility's failure to order medications in a timely manner, leading to missed doses. Staff members acknowledged that the resident's insulin requirements were high, which sometimes resulted in running out of insulin pens. However, there was no evidence that the facility took appropriate steps to address these shortages or notify the physician of the missed doses.
Improper Cleaning of Glucometer After Use
Penalty
Summary
The facility failed to ensure proper cleaning of a glucometer after blood glucose testing for one of the residents observed. During an observation, a Licensed Practical Nurse (LPN) used an alcohol wipe instead of the required germicidal wipes to clean the glucometer after testing a resident's blood glucose levels. The LPN admitted to not having the appropriate wipes on the medication cart and mentioned that they would need to go to Central Supply to obtain them. This action was contrary to the facility's policy and the manufacturer's instructions, which specify the use of EPA-registered germicidal wipes for disinfecting the glucometer. The resident involved in the incident was admitted to the facility with a diagnosis of type two diabetes mellitus and was receiving insulin treatment as per a sliding scale. The Unit Manager confirmed that each diabetic resident has their own glucometer and that alcohol wipes are not to be used for cleaning. The Director of Nursing (DON) acknowledged awareness of the incident and emphasized that all medication carts should be stocked with the proper cleaning supplies, and nurses should inform their managers if supplies are missing.
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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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