Savannah Post Acute Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Savannah, Georgia.
- Location
- 815 East 63 Street, Savannah, Georgia 31405
- CMS Provider Number
- 115120
- Inspections on file
- 21
- Latest survey
- November 18, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Savannah Post Acute Llc during CMS and state inspections, most recent first.
A respiratory nurse technician provided tracheostomy care to a resident with an indwelling medical device without wearing a gown, as required by the facility's Enhanced Barrier Precautions policy. Although the technician wore a mask and gloves, the omission of a gown was inconsistent with posted signage and staff expectations, resulting in a failure to adhere to infection control protocols.
A resident with morbid obesity and muscle weakness, requiring maximal assistance with toileting and always incontinent, was repeatedly provided with incontinence briefs that were too small due to supply shortages. This led to leakage, embarrassment, and the need for additional bathing. Staff and supply personnel confirmed the shortage of the correct size briefs and the use of improperly sized products, resulting in a failure to maintain the resident's dignity.
A resident with significant cognitive and medical impairments reported a sexual abuse allegation to a nurse, who documented the incident in the progress notes but did not notify other staff or the Administrator. This resulted in the allegation not being reported to the State Agency within the required timeframe, contrary to facility policy.
A resident who was transferred to the hospital on two occasions did not receive a written bed hold notice as required by facility policy. Although an LPN included a blank bed hold policy in the transport packet, nothing was given directly to the resident. The DON confirmed that the resident should have received written notification at the time of each transfer, but no documentation was found.
A resident's MDS assessment was not accurately coded to reflect a PASRR Level II evaluation and associated serious mental illness, despite documentation of relevant diagnoses and an existing PASRR Level II approval. The MDS Coordinator was unaware of the resident's PASRR Level II status, leading to the deficiency.
A resident with documented bipolar disorder and anxiety disorder was not referred for a required PASRR Level II assessment. Review of the MDS and EMR confirmed the absence of the assessment, and the administrator verified that the necessary submission had not been made.
The facility did not develop or implement person-centered care plans for oxygen therapy as required, resulting in one resident lacking oxygen interventions in their care plan and two residents receiving oxygen at higher flow rates than ordered. Staff confirmed that care plan interventions were not addressed or followed, despite physician orders and documented care needs.
A resident with significant lower extremity impairment and a care plan requiring leg elevation was repeatedly observed in a wheelchair without a leg rest or footrest, leaving his right leg unsupported. The resident could not attach the device independently and did not receive staff assistance, despite staff acknowledging the necessity of the support due to his medical conditions.
Three residents with respiratory conditions were administered oxygen at flow rates higher than those ordered by their physicians. Staff, including an RT and LPN, acknowledged the discrepancies, and the DON confirmed that oxygen was not provided according to orders. Facility policy required verification and adherence to physician orders for oxygen administration.
Several residents with intact cognition reported not being offered meal choices when eating in their rooms, receiving only the meal provided or a peanut butter and jelly sandwich as an alternative. Observations showed discrepancies between posted menus, tray tickets, and actual meals served, with residents not informed of their options. The Dietary Manager and Administrator confirmed these practices did not align with facility policy.
A resident with dementia and cognitive impairments exhibited wandering and exit-seeking behaviors, but the facility failed to include these issues in the care plan until after the resident eloped. The facility's policy requires comprehensive care plans, but staff confirmed the absence of interventions for elopement prior to the incident.
A resident with dementia and cognitive impairments eloped from the facility and was unaccounted for over an hour due to inadequate supervision and failure to follow the elopement risk policy. The resident exhibited exit-seeking behavior, but no elopement risk assessment or alarm was in place. The front door was not properly secured, and staff were not consistently present to monitor it, allowing the resident to exit unnoticed.
The facility failed to ensure adequate nursing staff for the first quarter of 2024, resulting in a One-Star Staffing Rating due to issues such as failure to submit PBJ data by the deadline and more than four days without RN staffing hours. The deficiency had the potential to adversely affect the care and services provided to the 109 residents.
The facility failed to ensure that three of four Certified Medication Aides (CMAs) completed a Medication Administration Competency Skills Checklist before administering medications to residents. Interviews and document reviews revealed missing competency checklists, and both the Director of Nursing (DON) and Administrator were unaware of the oversight.
The facility failed to maintain kitchen cleanliness and equipment maintenance, with observations of grease buildup, rust, and expired quaternary test strips. Interviews revealed a lack of a cleaning schedule and inadequate deep cleaning. The VP of Clinical Operations confirmed the deficiencies and emphasized the need for proper maintenance.
The facility failed to maintain the outdoor garbage and refuse area in a sanitary manner, with two dumpsters found open and surrounded by uncompressed empty boxes and visible trash bags. The District Manager confirmed that the previous day's dumpster pick-up had not been made, and the kitchen staff was responsible for maintaining the dumpsters.
The facility failed to ensure proper infection control practices were followed during a COVID-19 outbreak. Staff did not change masks when entering and exiting COVID-19 TBP rooms and left TBP room doors open, despite the facility's policies. Interviews revealed a lack of awareness and adherence to these policies.
The facility failed to periodically review antibiotic prescribing practices and did not document follow-up measures for infection control data over 12 months. The Antibiotic Stewardship Log lacked documentation, and the Antibiotic Medications Reports did not include necessary details such as organism susceptibility or if infections met McGeers criteria. The DON confirmed that trending, surveillance, and monthly infection control meetings were not conducted.
The facility failed to designate a qualified Infection Control Preventionist (ICP) for two of the last 12 months and did not ensure that the staff assigned to the role had enough time to perform ICP responsibilities for six of the last 12 months. Infection tracking and trending were not completed since November 2023, and monthly infection control meetings were not conducted. The DON admitted to not having enough time to manage the program effectively while performing her dual roles as DON and ICP, and she was not adequately trained in the Infection Control program.
The facility failed to complete 42 out of 101 grievance forms, resulting in unresolved grievances and dissatisfaction among residents. Interviews revealed that residents did not receive follow-up or resolution for their grievances, and some were unaware of the grievance process. The Administrator confirmed the ineffectiveness of the grievance process.
The facility failed to ensure that three residents did not have unsecured and unauthorized medication or medicated treatment products at their bedside. Medications were found unsecured in the rooms of residents who had not been assessed for self-administration, posing potential risks. Staff were unaware of the presence of these medications, and the DON confirmed that no residents had been assessed for safe self-administration.
The facility failed to post a complete listing of how to report abuse, including necessary contact details and instructions. Observations revealed the posted information only included a phone number. Most residents were unaware of what to report or how to report it, and the DON confirmed the posting lacked essential details.
The facility failed to report the misappropriation of property to the State Survey Agency for two residents who were investigated for abuse. Both residents reported missing money, but the grievances were not reported to the State Agency as required by the facility's policy. Interviews revealed that the facility did not follow its reporting process.
The facility failed to thoroughly investigate abuse and misappropriation allegations for four residents. Key personnel were not informed, and proper procedures for investigation and documentation were not followed, leaving residents without resolution or communication regarding their concerns.
The facility failed to develop or implement comprehensive care plans for three residents, leading to potential risks for medical complications and unmet needs. One resident lacked a care plan for contracture management and had undocumented oxygen therapy. Another resident's dialysis care plan was not followed due to missing communication forms. A third resident did not have a care plan for oxygen therapy despite relevant diagnoses. The DON and an LPN confirmed these deficiencies.
The facility failed to provide scheduled baths or showers for a resident with multiple diagnoses, including muscle weakness and bilateral below-the-knee amputations. Despite the resident's care plan indicating the need for supervision with minimal assistance for ADL care, documentation revealed that the resident only received two showers in the past 25 days. Interviews confirmed the resident had not received a shower in two weeks, and the Director of Nursing acknowledged the failure to adhere to the bathing schedule.
A resident readmitted with multifocal pneumonia did not receive prescribed Levaquin due to a failure in transcribing the medication order. The delay in administering the antibiotic was acknowledged by both the LPN and DON, who confirmed the oversight and lapse in care.
A resident with limited ROM did not receive the necessary PROM exercises and splint application as required by her condition. Staff were unaware of the resident's needs, and the facility's policy on contracture management was not followed, resulting in the resident not receiving the necessary care to prevent worsening contracture.
The facility failed to provide proper respiratory care for four residents, including not ensuring current physician's orders for oxygen therapy, not maintaining clean oxygen concentrators and filters, not providing humidification for oxygen therapy, and not documenting daily tracheostomy inner cannula changes. Staff interviews confirmed these deficiencies.
The facility failed to ensure ongoing communication and collaboration with the dialysis center for a resident requiring dialysis services. Despite a policy mandating the completion and submission of dialysis communication forms, the forms were missing and not being sent to the dialysis clinic. Staff interviews confirmed the deficiency, and the dialysis clinic had stopped following up after repeated failures to receive the forms.
Failure to Follow Enhanced Barrier Precautions During Tracheostomy Care
Penalty
Summary
The facility failed to ensure that respiratory staff followed infection control practices during tracheostomy care for a resident with a tracheostomy. According to the facility's Enhanced Barrier Precautions (EBP) policy, staff are required to wear gowns and gloves during high-contact care activities, such as tracheostomy care, for residents with indwelling medical devices. Observation revealed that the respiratory nurse technician provided tracheostomy care to a resident who was dependent for activities of daily living and had multiple diagnoses, including respiratory failure, without wearing a gown as required by the EBP protocol. The technician wore only a mask and gloves during the procedure, despite signage on the resident's door indicating the need for both gown and gloves. Interviews with staff confirmed inconsistent understanding and implementation of the EBP requirements. The respiratory nurse technician stated that he wore a gown only for residents on contact isolation precautions, not for those on EBP, while another respiratory nurse technician and the Director of Nursing both indicated that a gown should be worn during tracheostomy care for residents on EBP. This inconsistency in following established infection control protocols led to the deficiency identified during the survey.
Failure to Provide Correct Size Incontinence Briefs Compromises Resident Dignity
Penalty
Summary
The facility failed to provide care in a manner that maintained or enhanced the dignity and respect of a resident who required maximal assistance with toileting hygiene and was always incontinent of bladder and bowel. The resident, who had diagnoses including morbid obesity and muscle weakness, reported that the facility often ran out of the correct size incontinence brief, resulting in the use of a smaller size that caused leakage. This situation led the resident to feel embarrassed and to request a bath each time leakage occurred. Staff interviews confirmed that residents were measured for brief size and that there were occasions when the correct size was unavailable, leading to the use of briefs from other residents' supplies, which might not fit properly. The Central Supplies Clerk acknowledged that the facility was running out of the 3x-size briefs, and the Administrator was aware that the resident was receiving a smaller brief than needed. The care plan for the resident included regular checks and provision of incontinence care, but the lack of appropriate supplies resulted in a failure to uphold the resident's dignity.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse in a timely manner for one resident. According to the facility's policy, any allegation of neglect, exploitation, mistreatment, or misappropriation of resident property must be reported to the State Regulatory Agency within 24 hours. However, a review of the clinical record and incident report revealed that a resident, who was unable to complete a cognitive interview and had diagnoses including schizophrenia, diabetes mellitus with hyperglycemia, and muscle weakness, reported to the nurse's station that a man was in her room and attempted to sexually assault her. The nurse who received this report only documented the incident in the progress notes and did not notify other staff or the Administrator. As a result, the allegation was not reported to the State Agency within the required timeframe. The Assistant Director of Nursing confirmed that the delay occurred because the nurse failed to follow reporting procedures, and the Administrator acknowledged that the incident was not reported as required by policy. There was no documentation indicating that the abuse allegation was communicated to appropriate personnel or authorities in a timely manner.
Failure to Provide Written Bed Hold Notice During Hospital Transfers
Penalty
Summary
The facility failed to provide a written bed hold notice to one resident during two separate transfers to the hospital. According to the facility's Bed Hold and Returns Policy, residents and their representatives are to receive written information prior to transfer that details their rights and limitations regarding bed holds, the reserve bed payment policy, and the facility per diem rate for holding a bed. Review of the resident's clinical record showed no evidence that such a notice was provided during either transfer. The resident, who was cognitively intact and acted as his own responsible party, confirmed in an interview that he did not receive a written bed hold notice on either occasion. Staff interviews revealed that the process for providing bed hold information was not consistently followed. An LPN stated that while she included a blank bed hold policy in the packet sent with transport, she did not provide anything in writing directly to the resident. The DON confirmed that the resident should have received a written bed hold policy at the time of each transfer and acknowledged that there was no record of this occurring for the resident in question.
Inaccurate MDS Coding for PASRR Level II Resident
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded for a resident with a Pre-Admission Screening and Resident Review (PASRR) Level II. Review of the resident's annual MDS indicated that Section A did not reflect that the resident had been evaluated by Level II PASRR and determined to have a serious mental illness or related condition, despite Section I documenting diagnoses such as anxiety disorder, depression, and bipolar disorder. Further review of the electronic medical record confirmed the resident's admission and a PASRR Level II approval date. During staff interview, the MDS Coordinator acknowledged being unaware of the PASRR Level II approval for the resident, resulting in the inaccurate coding on the MDS.
Failure to Complete PASRR Level II Assessment for Resident with Serious Mental Illness
Penalty
Summary
The facility failed to ensure that a resident with diagnoses of bipolar disorder with psychotic features and anxiety disorder received a required Pre-Admission Screening and Resident Review (PASRR) Level II assessment. Review of the resident's Annual Minimum Data Set (MDS) and electronic medical record (EMR) showed no evidence of a PASRR Level II evaluation, despite documentation of serious mental illness. The resident was not included on the facility's list of individuals with PASRR Level II, and the administrator confirmed that no submission for the assessment had been made, even though it was required based on the resident's diagnoses.
Failure to Develop and Implement Person-Centered Oxygen Therapy Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans for residents receiving oxygen therapy, as required by their own policy. For one resident with diagnoses including COPD and acute respiratory failure with hypoxia, the care plan did not include any interventions for the use of oxygen, despite a physician's order for continuous oxygen at 2 liters per minute (LPM) via nasal cannula. Observations showed this resident was receiving oxygen at a higher flow rate of 3.5 LPM. For two other residents with similar respiratory diagnoses and physician orders for oxygen at 2 LPM, care plans did include interventions for oxygen use, but staff did not follow these interventions, as both residents were observed receiving oxygen at 3.5 LPM instead of the ordered rate. Staff interviews confirmed that the care plan interventions were not addressed or followed for these residents, and the MDS Coordinator acknowledged that the care plan serves as a blueprint for nursing care. The failure to develop and implement appropriate, individualized care plans for oxygen therapy was identified through review of medical records, care plans, physician orders, and direct observation of care.
Failure to Provide Wheelchair Leg Rest Support for Resident with Lower Extremity Impairment
Penalty
Summary
A resident with multiple medical conditions, including peripheral vascular disease, a stage four pressure ulcer, contracture of the right knee, hemiplegia, and an above-knee amputation, was observed on several occasions sitting in a wheelchair without a supportive leg rest or footrest. The resident was seen propelling himself in the hallway and sitting in various areas of the facility with his right lower extremity elevated and unsupported, despite having a care plan intervention to elevate his legs when sitting. The resident reported that he had a leg rest with an attached footrest but was unable to attach it himself and did not receive assistance from staff. Staff interviews confirmed that the resident should not be positioned in his wheelchair without the leg rest/footrest due to his medical conditions, including an ankle ulcer and contracture. The DON stated she was unaware that the device was not attached and that it was the responsibility of nursing staff to ensure the leg rest/footrest was applied daily. The failure to provide and secure the supportive device as required resulted in the resident repeatedly being left without necessary support for his lower extremity.
Failure to Administer Oxygen Therapy per Physician Orders
Penalty
Summary
Staff failed to administer oxygen therapy to three residents in accordance with physician orders. For one resident with COPD and acute respiratory failure, observations showed oxygen was delivered at 3.5 LPM via nasal cannula, despite a physician order for 2 LPM continuously. Another resident with COPD was observed receiving oxygen at 4.5 LPM, while the physician order specified 2 LPM. The respiratory therapist acknowledged increasing the flow rate due to a low oxygen saturation reading but confirmed this was not per the physician's order. The Director of Nursing confirmed that both residents were receiving oxygen at incorrect flow rates and stated that staff should not alter oxygen flow without a physician's order. A third resident, with COPD and chronic respiratory failure, was observed receiving oxygen at 3.5 LPM, though the physician order was for 2 LPM. The resident reported that the oxygen had been set at 3.5 LPM since admission, and a nurse confirmed the discrepancy between the order and the administered flow rate. The nurse also stated that it was the responsibility of nursing staff to ensure the correct oxygen flow rate. These findings were based on observations, staff interviews, and review of medical records and facility policy.
Failure to Offer Meal Choices and Follow Menus
Penalty
Summary
The facility failed to ensure that residents were offered meal choices and that menus were followed as required by policy. Multiple residents with little to no cognitive impairment reported that when they received meals in their rooms, they were not given a choice of food, and the only alternative offered was a peanut butter and jelly sandwich. Residents stated they received whatever the facility provided without being informed of the menu or given an opportunity to select their meals. This lack of choice was specifically noted for residents who ate in their rooms, while those who ate in the dining room were able to make meal selections. Additionally, there were discrepancies between the meals listed on the posted menus, the meal tray tickets, and the actual food served to residents. For example, one resident was served meals that did not match either the tray ticket or the posted menu on two separate occasions. The Dietary Manager confirmed that residents receiving meals in their rooms were not informed of their meal options and could not explain the inconsistencies between the posted menus, tray tickets, and meals served. The Administrator acknowledged that all residents should be informed of the menu and offered alternatives, and that the posted meals should be served as written.
Failure to Develop Care Plan for Wandering Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with a history of wandering and exit-seeking behaviors, which increased the potential for the resident not to receive appropriate treatment and care. The facility's policy on Person Centered Care Plans mandates that a comprehensive, person-centered care plan with measurable objectives and timetables be developed and implemented for each resident, addressing their physical, psychosocial, and functional needs. However, the resident's care plan lacked focus areas, goals, or interventions for wandering or elopement until after an incident occurred. The resident, diagnosed with dementia and other cognitive impairments, exhibited wandering behavior and exit-seeking tendencies, as documented in the clinical records and staff interviews. Despite these behaviors being noted, the care plan did not include interventions for elopement until after the resident was found outside the facility. Interviews with the Director of Nursing, the Administrator, and the MDS Coordinator confirmed the absence of a care plan addressing these behaviors prior to the incident, highlighting a delay in assessing the resident for elopement risks.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and protective oversight to prevent the elopement of a resident diagnosed with dementia and other cognitive impairments. The resident, identified as R1, was able to exit the facility and remain unaccounted for by staff for over an hour. The facility's policy on elopement risk and prevention was not followed, as no elopement risk assessment was completed for R1 prior to the incident, despite documented behaviors indicating a risk of wandering and exit-seeking. On the day of the incident, R1 exhibited increased agitation and confusion, expressing a desire to leave the facility and return home. Staff interviews revealed that R1 had a history of asking to go home and had been confused for several months. Despite these behaviors, no wander or elopement alarm was used for R1, and the resident was able to leave the facility through the front door, which was not properly secured. The front exit door had a delay in latching, and staff were not consistently present to monitor the door, allowing R1 to exit unnoticed. Interviews with staff indicated a lack of training and awareness regarding elopement prevention. The receptionist, who was responsible for monitoring the front door, was not present at the time of R1's exit, and the door was not locked. Maintenance staff were unaware of the door's malfunction until after the incident. The Director of Nursing confirmed the delay in assessing R1 for elopement risk, and the facility's failure to ensure staff presence at the front door contributed to the resident's unsupervised departure.
Inadequate Nursing Staff for Q1 2024
Penalty
Summary
The facility failed to ensure adequate nursing staff for the first quarter of 2024, as evidenced by a review of the Payroll-Based Journal (PBJ) Staffing Data Report and the Facility Assessment Tool 2024. The PBJ Staffing Data Report for Quarter 1 2024 revealed that the facility triggered a One-Star Staffing Rating due to several issues, including failure to submit PBJ data by the deadline, more than four days in the quarter without Registered Nurse (RN) staffing hours, and failure to respond to or pass a CMS audit designed to discover discrepancies in PBJ data. The Facility Assessment Tool 2024 indicated that the average daily census was 106 to 109 residents, and the staffing plan documented the number of staff available to meet residents' needs, which included eight licensed nurses for days and four for evenings, 12 CNAs for days and eight for evenings, four to six CNAs for nights, and one to two CMTs available for care during those shifts. Interviews with the Director of Nursing (DON) and the Nursing Scheduler (NS) III revealed that they were aware of the facility's one-star staffing rating for the first quarter of 2024, attributing it to the facility's high turnover rate and reliance on staffing agencies. The Administrator also acknowledged awareness of the one-star staffing rating. The deficient practice had the potential to adversely affect the care and services provided to the 109 residents residing in the facility.
Failure to Ensure Medication Administration Competency for CMAs
Penalty
Summary
The facility failed to ensure that Certified Medication Aides (CMAs) met professional standards of quality by not providing evidence that three of four CMAs completed a Medication Administration Competency Skills Checklist before being allowed to administer medications to residents. This deficiency was identified through staff interviews and a review of facility documents, which revealed that the required competency checklists were missing for the majority of the CMAs employed at the facility. The facility's document titled Certified Medication Aide Bi-Annual Checklist indicated that an RN or Pharmacist should conduct an annual competency assessment, but this was not adhered to for three of the four CMAs reviewed. Interviews with the CMAs and the Director of Nursing (DON) confirmed the lack of completed competency checklists. One CMA stated she had only been observed once by a consultant pharmacist since being hired, while another CMA reported not having completed any medication administration skills checkoff. The DON acknowledged awareness of the requirement but could not provide additional information or documentation to confirm the completion of the checklists. The Administrator was also unaware that the CMAs had not completed the required checkoffs, indicating a lapse in oversight and adherence to the facility's own policies and procedures.
Kitchen Cleanliness and Equipment Maintenance Deficiencies
Penalty
Summary
The facility failed to ensure that the kitchen walls, floors, and equipment were clean and free of rust, debris, and grease buildup, and also failed to use un-expired quaternary test strips in the three-compartment sink. Observations revealed a sticky, brown, greasy substance and debris behind the oven and surrounding area, a dusty ventilation unit on the juice machine, and a build-up of rust and dust on the fire extinguisher located next to the handwashing sink. Additionally, water puddles were observed on the floor near the three-compartment sink, and the water from the handwashing sink would not turn off completely. The Food Service Manager (FSM) confirmed these observations. Expired quaternary test strips were also found in use at the three-compartment sink, which was confirmed by the FSM. Interviews with dietary aides revealed a lack of a cleaning list or schedule, and it was noted that water was usually present on the floor around the sinks. The FSM stated that although staff did a lot of scrubbing and cleaning, the grease and grime buildup was due to the old building. Dietary aides confirmed that they had never seen anyone clean the ventilation units or filters, nor had they observed deep cleaning or repairs in the kitchen. During a walk-through, the VP of Clinical Operations confirmed that the kitchen was not clean and needed deep cleaning, and that the fire extinguisher near the hand-washing sink needed cleaning. The VP expressed expectations that dietary staff should maintain cleanliness in the kitchen and ensure all equipment is in good working condition.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure the outdoor garbage and refuse area was free of litter and maintained in a sanitary manner for two of two dumpsters. During an initial observation, the Food Service Manager and the District Manager verified that the dumpsters were open and filled with visible black trash bags and boxes. Additionally, uncompressed empty boxes were found surrounding the dumpsters. The District Manager and FSM confirmed that the dumpsters should have been closed and free of trash or boxes on the ground around them. In an interview, the District Manager confirmed that the previous day's dumpster pick-up had not been made, and the Maintenance Director had called for an alternative pick-up. The District Manager also confirmed that maintaining the dumpsters was the kitchen staff's responsibility. The facility's policies on garbage disposal and environmental maintenance were reviewed, revealing that the procedures were not followed as required, leading to the observed deficiencies.
Failure to Follow Infection Control Practices During COVID-19 Outbreak
Penalty
Summary
The facility failed to ensure proper infection control practices were followed to prevent the transmission and spread of COVID-19. Specifically, staff did not change their masks when entering and exiting COVID-19 Transmission-Based Precaution (TBP) rooms and did not close the doors of two COVID-19 TBP rooms during care. Observations revealed that staff, including a Restorative Aide, Certified Nursing Assistants (CNAs), and a housekeeper, repeatedly left TBP room doors open and did not change their masks as required by the facility's policies. These actions occurred despite the facility being in an outbreak status, with 31 residents and 11 staff members testing positive for COVID-19. Interviews with staff indicated a lack of awareness and adherence to the facility's infection control policies. For instance, a Restorative Aide admitted she did not realize the TBP room doors were open and acknowledged that they should remain closed. Additionally, a CNA revealed she had not received updated COVID-19 or infection control education since the current outbreak began. The Director of Nursing (DON) confirmed that she was only recently made aware of the issue with the TBP room doors being left open and stated that staff were re-educated on the importance of containing the spread of infections and illness.
Failure to Monitor and Document Antibiotic Use
Penalty
Summary
The facility failed to provide evidence of a process for periodic review of antibiotic prescribing practices and did not document follow-up measures in response to the data for 12 of 12 months of infection control data reviewed. The facility's policy titled Antibiotic Stewardship, dated 2/1/2024, stated that antibiotics would be prescribed and administered under the guidance of the facility's Antibiotic Stewardship Program. However, the facility's Antibiotic Stewardship Log lacked documentation for several months, and there was no testing data to determine if infections met the McGeers criteria or were facility or community-acquired. Additionally, the Antibiotic Medications Reports from the pharmacy did not document the organism, if a culture was performed, or the organism's susceptibility to the prescribed antibiotic, nor did it indicate if the McGeers criteria were met or if the infection was a true infection. The facility's calculated infection rate was the only documented data for April 2023 through March 2024. The Director of Nursing (DON) confirmed that the program's trending, surveillance, and monthly calculation rates were not being monitored, and monthly infection control meetings were not conducted in the facility. The President of Clinical Services revealed that the Infection Control Program, particularly the Antibiotic Stewardship Program, did not utilize floor plan mapping effectively or track organisms and perform surveillance. She had educated the DON on the process but had not followed up to see if it was implemented. The DON stated that there had not been a specific person monitoring the Antibiotic Stewardship Program since December 2023.
Failure to Designate and Support Qualified Infection Control Preventionist
Penalty
Summary
The facility failed to designate a qualified staff member to the role of Infection Control Preventionist (ICP) for two of the last 12 months and did not ensure that the staff assigned to the role had enough time to perform ICP responsibilities for six of the last 12 months. This deficiency was identified through record reviews, staff interviews, and a review of the facility document titled Healthcare Center Infection Preventionist. The facility's infection surveillance documentation was missing from November 2023 to April 2024, and there were no line listings for infectious illnesses for January, February, and March 2024. The Director of Nursing (DON) and the newly appointed ICP confirmed that infection tracking and trending had not been completed since November 2023, and monthly infection control meetings were not conducted during this period. The DON admitted to not having enough time to manage the program effectively while performing her dual roles as DON and ICP, and she was not adequately trained in the Infection Control program. The DON stated that she was responsible for infection control from March 2023 through December 2023, and a staff member who is no longer employed by the facility was responsible for infection control in January 2024. No one was responsible for infection control from February 2024 through March 2024, and the new ICP began the position in April 2024. The DON also mentioned that she had requested help from the Corporation's President but did not receive adequate support. The lack of proper infection surveillance and documentation, along with the absence of a designated and trained ICP, contributed to the facility's failure to maintain an effective Infection Prevention program, potentially putting all residents at risk of infectious diseases. The facility had a census of 109 residents at the time of the survey.
Incomplete Grievance Forms and Lack of Follow-Up
Penalty
Summary
The facility failed to thoroughly complete resident grievance forms, resulting in unresolved grievances and dissatisfaction among residents. A review of 101 grievance forms revealed that 42 were incomplete, lacking evidence of thorough investigation, resolution, and follow-up to ensure resident satisfaction. During a Resident Council Meeting, several residents reported that they had filed grievances but did not receive any follow-up or resolution. Some residents were unaware of the grievance process altogether. Interviews with staff, including the Activity Director and the Administrator, confirmed that the grievance process was ineffective. The Activity Director mentioned that she would submit complaints to the Administrator if residents reported no follow-up. The Administrator, who started working at the facility on 2/5/2024, acknowledged the problem with the grievance process and confirmed that no effective process was in place when she began her tenure. The deficiency had the potential to adversely affect any resident who filed a grievance.
Unsecured and Unauthorized Medications at Bedside
Penalty
Summary
The facility failed to ensure that three residents (R30, R32, and R71) did not have unsecured and unauthorized medication or medicated treatment products at their bedside. For R30, a bottle of fluticasone was found unsecured on the bedside table, and the resident had not been assessed for self-administration of medication. The Infection Control Preventionist confirmed the presence of the medication but did not remove it, and the Director of Nursing confirmed that R30 was not assessed for self-administration. Licensed Practical Nurses were unaware of the medication at the bedside and confirmed that R30 was not assessed for self-administration. For R32, a container of Alka Seltzer Cold Medicine and a jar of Zinc Oxide Skin Protectant cream were found unsecured on the bedside table. R32 had a moderate cognitive impairment and had not been assessed for self-administration of medication. The medications were removed by an LPN who confirmed that the resident was not assessed for self-administration and that the zinc oxide ointment was not ordered. For R71, a bottle of rubbing alcohol and a bottle of hydrogen peroxide were found unsecured on the bedside nightstand. The resident had not been assessed for self-administration of medication, and the LPN confirmed the unsecured medications and removed them. The DON stated that no residents in the facility had been assessed for safe self-administration of medications.
Incomplete Abuse Reporting Information
Penalty
Summary
The facility failed to post a complete listing of how to report abuse and the types of abuse, including a mailing address, email address, and information on how to report to the State Agency in a manner accessible to residents and visitors. During the initial tour and daily walks throughout the building, it was observed that the posted information only included a phone number for the Georgia Department of Community Services. During a Resident Council Meeting, the majority of residents did not know what information to report or how to report it, and none could identify the location of the posting. The Director of Nursing confirmed the posting lacked the correct agency name, address, telephone number, and detailed instructions on reporting different types of abuse. The Administrator also confirmed the incomplete information on the sign and acknowledged the issue.
Failure to Report Misappropriation of Property
Penalty
Summary
The facility failed to report the misappropriation of property to the State Survey Agency (SSA) for two residents who were investigated for abuse. Resident 41 reported missing six hundred dollars, which he claimed to have handed to the receptionist upon admission. The Social Service Assistant (SSA) documented the grievance but did not report it to the Social Services Director (SSD) or the State Agency. Similarly, Resident 45 reported missing $7.80, which she had placed in her bra. The SSA documented this grievance but also failed to report it to the State Agency. Both grievances were not signed or dated by the Administrator, indicating a lapse in the reporting process. Interviews with the residents, SSA, Director of Nursing (DON), and the Administrator revealed that the facility did not follow its policy for reporting allegations of misappropriation of property. The DON was unaware of the missing money incidents, and the Administrator did not recall being informed about them. The facility's policy required that such allegations be reported to the State Agency within 24 hours, but this was not done. The Administrator acknowledged that the initial report should have been filed with the State Agency, the police notified, and a five-day follow-up report sent to the State office after the investigation.
Failure to Investigate Abuse and Misappropriation Allegations
Penalty
Summary
The facility failed to ensure that abuse allegations, specifically an allegation of physical abuse and allegations of misappropriation of resident property, were thoroughly investigated for four residents. The facility's policy required that all allegations be investigated and documented, but this was not done in several instances. For example, a resident with severe cognitive impairment reported physical abuse, but the investigation was not documented, and key personnel were not informed. The Director of Nursing (DON) and the Administrator were unaware of the incident, and the Social Services Director (SSD) admitted to not following proper procedures for investigation and documentation. Another resident with moderate cognitive impairment reported missing $600, but the investigation was incomplete. The Social Service Assistant (SSA) checked the facility's safe but did not follow up further or inform the resident about the investigation's outcome. The grievance form was not signed by the Administrator, and the resident was left without any resolution or communication regarding the missing money. Two other residents also reported missing money, but their allegations were not thoroughly investigated. One resident reported $7.80 missing, and the SSA did not document interviews with other residents or staff. Another resident reported $36 missing, and the SSD did not document the investigation or interview staff who had access to the resident's room. The DON and the Administrator were unaware of these incidents, and the facility did not follow its policy for investigating and documenting such allegations.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop or implement comprehensive, person-centered care plans for three residents, leading to potential risks for medical complications and unmet needs. For one resident, the facility did not develop a care plan for contracture management despite the resident's diagnoses of hemiplegia, hemiparesis, and functional quadriplegia. Additionally, the care plan for oxygen therapy was not followed, as evidenced by the lack of documentation for oxygen administration and oxygen saturation checks. The Director of Nursing (DON) confirmed these deficiencies during an interview, acknowledging the absence of a contracture management care plan and the failure to document respiratory care interventions. Another resident's care plan for dialysis was not properly implemented, as there were no current dialysis communication forms in the electronic medical record (EMR), with the last one filed several months prior. The DON confirmed that the care plan interventions were not being followed due to the lack of communication with the dialysis center. Additionally, a third resident did not have a care plan for oxygen therapy despite having diagnoses of acute respiratory failure and pneumonia. The DON and a Licensed Practical Nurse (LPN) both verified the absence of the care plan, and the Administrator was unaware of this deficiency. These failures indicate a lack of adherence to the facility's policy on developing and implementing individualized care plans.
Failure to Provide Scheduled Baths or Showers
Penalty
Summary
The facility failed to provide assistance with activities of daily living (ADL), specifically baths or showers, for one resident (R5) out of 54 sampled residents. The facility's policy titled Bathing-Shower, effective 2/1/2024, outlines the purpose and procedure for bathing residents, including providing the opportunity to bathe according to preference and revising the bathing plan as needed. Despite this policy, R5, who has multiple diagnoses including muscle weakness, type 2 diabetes mellitus, and bilateral below-the-knee amputations, did not receive the required assistance with bathing. R5's care plan, revised on 3/7/2024, indicated the need for supervision with minimal assistance for ADL care, including bathing. However, documentation revealed that R5 only received two showers in the past 25 days, and there was no record of any baths from April 1, 2024, to April 6, 2024. Interviews with R5 confirmed that he had not received a shower in two weeks, despite being scheduled for showers twice a week. The Director of Nursing (DON) confirmed that bath sheets, which track when showers or baths are given, were completed for all residents, and any refusals were to be documented and reported for care plan revisions. However, the DON acknowledged that only two bath sheets were completed for R5 in the last 25 days, indicating a failure to provide the scheduled baths or showers. Interviews with Certified Nursing Assistants (CNAs) revealed that staff generally followed the bath schedule, but if a bath sheet was not completed, it meant the shower or bath was not provided. This failure to adhere to the bathing schedule and properly document care placed R5 at risk for unmet needs and a diminished quality of life.
Failure to Transcribe and Administer Antibiotic Medication Order
Penalty
Summary
The facility failed to transcribe and administer an antibiotic medication order for a resident (R49) as prescribed by the physician, resulting in a delay in treatment. R49 was readmitted to the facility from an acute care hospital with a diagnosis of multifocal pneumonia and a discharge medication list that included Levaquin 750 mg daily for five days starting on 4/5/2024. However, the medication order was not transcribed into the electronic medical record (EMR) upon the resident's return, and the medication was not administered until 4/10/2024, five days after the prescribed start date. Interviews with the Licensed Practical Nurse (LPN) and the Director of Nursing (DON) revealed that the floor nurses were responsible for transcribing physician orders when residents returned from hospital stays. The LPN acknowledged the oversight and confirmed that the order for Levaquin was not entered into the EMR until 4/10/2024. The DON also acknowledged the lapse in care due to the delay in transcribing the medication order, which resulted in the resident not receiving the necessary antibiotic treatment in a timely manner.
Failure to Provide Necessary PROM and Splinting for Resident
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion (ROM) received the necessary passive range of motion (PROM) exercises and splint application to address her condition. The resident, who had diagnoses including hemiplegia and hemiparesis following a cerebral infarction, was observed multiple times without any splint or device in her hands to prevent contracture. The facility's policy on contracture management was not followed, as the resident was not on the restorative caseload and did not receive the required PROM or splinting services as indicated by her condition and previous therapy recommendations. Interviews with staff revealed a lack of awareness and communication regarding the resident's need for PROM and splinting. The Restorative Aides and Licensed Practical Nurse (LPN) responsible for the Restorative Nursing Program were unaware that the resident required these services. The Certified Nursing Assistants (CNAs) assigned to the resident did not perform or document the necessary exercises and splint application. The Rehabilitation Manager confirmed that the resident would benefit from therapy services and needed ROM for her left hand and an orthotic device for her right hand, but no referrals for screening had been made by the nursing department. The Director of Nursing (DON) acknowledged that the resident should have remained on the Restorative Nursing Program if a splint was required and that nursing staff should have informed her of any changes in the resident's condition. The DON was unaware that the resident no longer received PROM and splinting for her right hand or that her left hand had limited ROM. This lack of communication and adherence to the facility's policy resulted in the resident not receiving the necessary care to maintain or improve her ROM, potentially leading to worsening contracture, pain, or skin breakdown.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for four residents receiving respiratory services. Specifically, the facility did not ensure there was a current physician's order for oxygen therapy and oxygen saturation checks before administering oxygen, did not maintain clean oxygen concentrators and filters, and did not provide humidification for oxygen therapy for one resident. Additionally, the facility failed to document daily tracheostomy inner cannula changes for another resident, and did not clarify a physician's order for oxygen for a third resident. The facility also failed to follow physician's orders for oxygen, ensure the oxygen concentrator had a filter, and label and store respiratory equipment in a sanitary manner for a fourth resident. One resident with acute and chronic respiratory failure was observed receiving oxygen via nasal cannula at 4 liters per minute, but the oxygen concentrator's filter was dirty, and the humidification container was empty. The electronic medical record revealed no current order for oxygen therapy or oxygen saturation checks, and the Medication Administration Record did not document oxygen administration or saturation checks for the current month. Interviews with staff confirmed the deficiencies in maintaining the oxygen equipment and ensuring proper documentation and orders. Another resident with a tracheostomy had a physician's order to change the inner cannula daily, but there was no documentation that this was done for several days. Staff interviews confirmed the lack of documentation and adherence to the physician's order. A third resident's oxygen concentrator filter was found to be dirty, and the physician's order for oxygen therapy was not clearly defined. The fourth resident's oxygen concentrator did not have a filter, and the nasal cannula was not stored properly, with observations showing it lying on the floor and not in a protective bag. Staff interviews confirmed these deficiencies and the failure to follow physician's orders for oxygen therapy.
Failure to Ensure Ongoing Communication with Dialysis Center
Penalty
Summary
The facility failed to ensure ongoing communication and collaboration with the dialysis center for a resident (R60) who required dialysis services. The facility's policy titled Dialysis Care, effective 2/1/2024, mandated pre and post care for dialysis residents, including the completion and submission of dialysis communication forms to the dialysis center. However, a review of R60's electronic medical record revealed that the only dialysis communication form documented was dated 10/2023, despite a physician's order for dialysis services three times a week. Interviews with staff, including the Registered Nurse (RN), Director of Nursing (DON), and Central Supply/Medical Record Licensed Practical Nurse (LPN), confirmed that the dialysis communication forms were missing and not being sent to the dialysis clinic as required. The dialysis clinic had contacted the facility to request the forms but eventually stopped following up after the facility continued to fail to submit them. The deficiency was further corroborated by the Dialysis RN, who confirmed that the facility was not submitting R60's dialysis communication forms to the dialysis clinic at the time of the resident's dialysis appointments. The Administrator was also unaware of the issue and stated that her expectations were for the nursing staff to send the dialysis communication form to each dialysis appointment. This failure to adhere to the facility's policy and ensure proper communication with the dialysis center had the potential to place R60 at risk for medical complications, unmet needs, and a diminished quality of life.
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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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