Spalding Post Acute Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Griffin, Georgia.
- Location
- 415 Airport Road, Griffin, Georgia 30224
- CMS Provider Number
- 115537
- Inspections on file
- 23
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Spalding Post Acute Llc during CMS and state inspections, most recent first.
Surveyors found that staff failed to follow infection control and hand hygiene policies for two residents. For a resident with DM2 and severe cognitive impairment, an LPN handled a metformin tablet with bare hands while placing it in a pill cutter, contrary to facility expectations that medications not be handled with bare hands. For a resident with dysphagia and a feeding tube, an LPN changed gloves during G-tube care without performing hand hygiene between glove changes, citing an empty hand sanitizer dispenser and not washing hands instead. The nurse manager and DON confirmed that facility policy requires handwashing or use of alcohol-based hand rub after glove removal and between glove changes, and that these lapses constitute infection control issues.
A resident with COPD had a Stiolto Respimat inhaler at the bedside without a provider order, IDT assessment, or care plan for self-administration. The resident said he used the inhaler whenever he wanted, and an LPN confirmed the bedside meds were not authorized and that staff did not know when he used them. The DON confirmed the resident was not approved to self-administer medications.
Failure to Protect Residents from Abuse: A CNA was alleged to have kicked a resident with dementia while he was on the bathroom floor, and two other residents experienced resident-to-resident abuse from a cognitively impaired resident who stole food and exposed himself in a bathroom while making a sexual remark. The affected residents reported being scared or shocked, and the incidents were substantiated during the investigation.
Misappropriation of narcotic medications occurred when an LPN signed out pain meds for three residents but the eMAR did not show the meds were administered, and two residents stated they did not receive the medications. One resident had chronic pain and end-of-life care needs, another had metastatic lung cancer with a pain-related care plan, and a third had low back pain with opioid use documented. The facility’s investigation noted discrepancies between narcotic book signatures and actual administration records.
A resident with severe cognitive impairment, impaired mobility, and wheelchair use had a fall-risk care plan that included locking the wheelchair brakes when not in use and staff assistance. The resident had multiple falls without injury, and observation showed him trying to move a locked wheelchair and attempting to unlock it. Staff interviews showed inconsistent practice, with some staff leaving the wheelchair unlocked because of the resident’s free will or attempts to scoot and ambulate in it.
Advance Directive Care Plan Not Updated to Match DNR Order: A resident with a DNR order had a care plan that still stated the facility would honor the resident’s wishes and perform CPR in a medical emergency. The MDS Director, SSD, Nurse Manager, and DON all confirmed the conflict between the care plan and the physician’s DNR order, and the SSD stated the issue was an oversight.
Failure to supervise a resident at risk for falls: A resident with severe cognitive impairment, dementia, impaired mobility, and wheelchair use was care planned for fall prevention and wandering precautions, including locking wheelchair brakes when not in use. During observation, staff assisted the resident to the nurse's station and locked the wheelchair, but the resident later tried to move the locked wheelchair to ambulate and appeared confused. An LPN stated she does not routinely lock the resident's wheelchair because he should have free will, despite knowing the resident had been seen scooting in the chair when the wheel is locked.
Unsecured medication cart and unlabeled glucometer strips: One medication cart was observed unlocked and unattended in the hall, and one bottle of blood sugar strips in a cart drawer had no open date. The UM, an LPN, and the DON all confirmed that carts should be locked when not in use and that glucometer strips require an open date.
The facility failed to maintain an adequate Surety Bond to cover resident trust fund balances, with the bond set at $85,207.06 while monthly balances ranged from $107,015.20 to $144,539.69 over six months. The Administrator was unaware of the discrepancy, affecting 84 residents.
The facility failed to ensure that expired medications were removed from two medication storage rooms, potentially placing residents at risk. Expired containers of mineral oil lubricant laxative, iron supplement liquid, arthritis relief, and Geri Lanta were found and discarded by an LPN and an RN. The DON stated that nurses were instructed to check expiration dates when retrieving medications.
A resident with an indwelling urinary catheter had their dignity compromised when their catheter drainage bag was left uncovered and visible from the hallway, contrary to facility policy. The resident, dependent on assistance for daily activities and with a history of medical conditions, expressed concerns about privacy. Staff interviews confirmed the oversight, with the DON acknowledging the lapse in maintaining the resident's dignity.
A resident was found with unauthorized medications at their bedside without an assessment for safe self-administration. The facility's policy requires a licensed nurse and physician to determine the safety of self-administration, but no such evaluation was documented. Staff were unaware of the medications, and the DON confirmed that self-administration is not allowed without proper assessment and orders.
The facility failed to conduct required pre-employment background checks and fingerprinting for the DON and DM, as mandated by their policy on Abuse, Neglect, and Misappropriations. Despite the oversight, no concerns related to abuse or neglect were identified during the survey. The issue was attributed to a system error and the recent departure of the HR Manager.
A facility failed to develop a comprehensive care plan for a resident with an indwelling urinary catheter. Despite the resident's medical history, the care plan lacked specific interventions for the catheter. The MDS Coordinator confirmed this oversight, noting it was due to the resident's initial admission for respite care.
A facility failed to ensure a resident with an indwelling urinary catheter had a qualifying medical diagnosis for its use. The resident's medical record included conditions like hemiplegia and a history of UTIs, but no genitourinary diagnoses were documented. The catheter was ordered for a history of wounds, which was not clinically qualifying. The DON confirmed the deficiency.
A facility failed to maintain a medication error rate below five percent, resulting in a 10.34 percent error rate. An LPN administered incorrect dosages and formulations to two residents, including divalproex sodium and vitamin B12, contrary to physician's orders. The DON noted the LPN was new and needed more training.
The facility failed to follow infection control policies during care for three residents. An LPN did not sanitize hands between glove changes during a blood sugar test, a Wound Care Nurse did not sanitize surfaces or use barriers during wound care, and a syringe for a resident on tube feeding was improperly stored. These actions were contrary to the facility's infection prevention policies.
The facility failed to notify the Ombudsman of the discharge of six residents, as required by their policy. There was no documentation in the residents' medical records indicating that the Ombudsman was informed. Interviews with staff revealed a lack of awareness about this requirement, leading to non-compliance with the facility's policy.
The facility failed to follow infection control procedures for glucometer use, as observed with two LPNs who did not clean the devices after use or use barriers on surfaces. The facility's policy requires glucometers to be disinfected after each use, but this was not adhered to, leading to potential cross-contamination risks.
The facility failed to provide quarterly trust fund account statements to three residents, despite having a policy requiring such distribution. Interviews revealed that the residents had not received statements, with one resident not receiving any since February. The BOM acknowledged the responsibility for managing and distributing these statements, but the process failed, potentially affecting all residents with trust fund accounts.
The facility failed to promptly file grievances for two residents who reported concerns during resident council meetings. One resident raised issues about nebulizers and medication administration, while another reported dirty washcloths, foul-smelling laundry, and a missing wallet. Despite these concerns, no grievances were documented, indicating a failure to follow the facility's grievance policy.
Failure to Follow Hand Hygiene and Medication Handling Practices
Penalty
Summary
Surveyors identified a deficiency in the facility’s implementation of its infection prevention and control program and hand hygiene policies. The facility’s Handwashing/Hand Hygiene policy states that all personnel must follow hand hygiene procedures to prevent the spread of infections, including using alcohol-based hand rub or soap and water before and after direct resident contact and after removing gloves, and clarifies that glove use does not replace hand hygiene. The Infection Prevention and Control Program policy states the facility maintains a program to prevent the development and transmission of communicable diseases and infections according to accepted standards. For one resident with diabetes mellitus type 2, admitted with diagnoses including diabetes and assessed as having severe cognitive impairment, the physician’s orders directed administration of metformin 500 mg tablets, two tablets by mouth twice daily. During a medication pass, an LPN used her bare hands to place a metformin tablet into a pill cutter to split a 1000 mg tablet into two halves for administration, rather than using gloves or another barrier. The LPN later confirmed she had handled the tablet with bare hands and acknowledged that this could cause cross contamination. The DON stated her expectation that nurses do not handle medications with bare hands because bare hands could contaminate pills and residents could receive whatever contamination was on the pills, possibly infection. For another resident admitted with diagnoses including dysphagia, rarely or never understood, and receiving nutrition via a feeding tube, the care plan documented the need for bolus PEG tube feeding and monitoring for signs and symptoms of aspiration and infection at the tube site. Physician’s orders directed cleansing of the G-tube site with sterile saline, drying, applying skin protectant, and covering with split gauze secured with tape. During G-tube care, an LPN changed gloves but did not sanitize or wash her hands between glove changes. The LPN confirmed she did not perform hand hygiene between glove changes, explaining that the hand sanitizer station in the room was empty and acknowledging she should have washed her hands. The nurse manager and DON both confirmed that facility expectations are that staff wash or sanitize hands any time gloves are removed and between glove changes, and that failure to do so is an infection control issue that could lead to healthcare-associated infections.
Unapproved Bedside Inhaler Storage
Penalty
Summary
The facility failed to remove one Stiolto Respimat inhaler from the bedside of one resident, R94, who was included in a sample of 54 residents. R94 was admitted with a diagnosis that included COPD, and the quarterly MDS documented a BIMS score of 15, indicating little to no cognitive impairment. The facility’s policy required a physician or mid-level provider order, care planning, a secure locked area for medications, resident instruction, and periodic evaluation before self-administration or bedside storage of medications was allowed. Record review showed no documented care plan for self-administration of medication for R94, no physician’s order for self-administration, and no interdisciplinary team assessment for medication self-administration. The physician’s orders included Stiolto Respimat inhalation aerosol for COPD, with directions to give 2 puffs by mouth every morning and at bedtime and to evaluate the resident during inhalation therapy to ensure proper use and toleration. Observations on multiple occasions showed one Stiolto Respimat inhaler on R94’s overbed table, and later observations also found VapoCool sore throat spray and CareAll chest rub at the bedside. During interview, R94 stated the inhaler was his and had been at his bedside since admission, and that he used it whenever he wanted, up to a few times each day. He also stated he used the inhaler between times when nurses came to give him the facility’s inhaler medication. An LPN confirmed the medications were at the bedside and stated R94 should not have medications there or take them without staff knowledge. The DON confirmed the expectation that residents should not have medications at the bedside and acknowledged that R94 did not have a doctor’s order, IDT assessment, or care plan for self-administration.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to ensure three residents were free from abuse. One resident with dementia and a BIMS score of 0 was involved in an allegation of staff-to-resident abuse after another resident reported witnessing a CNA kick him while he was lying on the bathroom floor. The witness stated the resident had fallen in the doorway of the shared bathroom and remained on the floor for about 45 minutes before the CNA arrived, then the CNA kicked the resident multiple times and spoke to the witness in a foreign language in a voice and tone that frightened him. The investigation documented that the CNA was suspended pending the outcome, and the allegation was substantiated. The resident who witnessed the event had diagnoses including COPD, CKD, and hearing loss. The abused resident and the witness were both discharged from the facility by the time of the survey. The report also noted staff interviews, resident interviews, skin assessments, and abuse-related education were part of the investigation. The facility also had two incidents of resident-to-resident abuse involving another resident with severe cognitive impairment, including a BIMS score of 0, wandering behavior, dementia, alcoholism, malnutrition, traumatic subdural hemorrhage, and compression of the brain. He entered one resident's room and took her food, and he entered another resident's bathroom while urinating, exposing himself and making a sexual comment. The affected residents reported feeling scared and shocked, and one stated the incident was the only one of its kind before or since. The report states the facility policy prohibited abuse, neglect, exploitation, and misappropriation of resident property, yet these abuse events occurred.
Misappropriation of Narcotic Medications
Penalty
Summary
The facility failed to ensure three residents were free from misappropriation of medication when narcotic medications were signed out and not administered. The report cites the facility policy on abuse, neglect, and misappropriation, which states that alleged violations involving misappropriation of resident property are to be investigated and reported. For one resident with diagnoses including a left femur fracture and neoplasm of the tongue, the record showed a BIMS score of 15 and a care plan for pain medication therapy related to chronic pain and end of life care, with an order for oxycodone 10 mg every 4 hours as needed. The facility's investigation report stated that an LPN/UM signed out two 5 mg tablets on one date and two more 5 mg tablets on the next date, but the resident stated he only received pain medication once from that nurse. For a second resident with metastatic lung cancer and a BIMS score of 15, the care plan addressed risk of acute/chronic pain related to cancer and a history of right foot pain, with an order for hydrocodone-acetaminophen 5-325 mg every 6 hours as needed that was later discontinued. The investigation report stated that the LPN/UM removed a 5 mg/325 mg oxycodone from the cart per her signature in the narcotic book, but the eMAR did not document it as given, and the resident stated he did not ask for or receive pain medication and did not even take it. For a third resident with low back pain and a BIMS score of 12, the record showed opioid use and a care plan for pain medication therapy, but the report excerpt ends before the specific medication order details are provided.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement care plan interventions for a resident with impaired mobility, severe cognitive impairment, and use of a wheelchair, resulting in repeated falls without injury. The resident had diagnoses including medically complex conditions, non-Alzheimer's dementia, and macular degeneration. The quarterly MDS showed a BIMS score of 00 and extensive assistance needs for ADLs and mobility. The care plan identified a fall risk related to impaired mobility, impaired cognitive function, and psychotropic medication use, with interventions including staff assistance to and from the dining room and ensuring wheelchair brakes were locked when the wheelchair was not in use. Facility records showed the resident had falls without injury on three separate dates in March 2026. During observation, staff assisted the resident to the nurse's station and locked the wheelchair, but later the resident was seen trying to move the locked wheelchair, shuffling it to the left, and attempting to unlock it without success. Staff interviews revealed inconsistent practice: one LPN stated she did not lock the wheelchair because the resident should have free will, while a CNA stated staff often unlocked the wheelchair because the resident would attempt to ambulate in it when locked and would scoot side by side in the chair. The MDS Director stated the MDS team updates care plans and communicates changes, but has no responsibility to ensure interventions are implemented. The Administrator stated the resident knows how to unlock the wheelchair on some days and not others, and that staff do the best they can to manage his care.
Advance Directive Care Plan Not Updated to Match DNR Order
Penalty
Summary
The facility failed to update the care plan for Advance Directives for one resident, R94, whose record showed a DNR order. Review of the facility’s policies stated that each resident should have an individualized interdisciplinary plan of care and that the plan of care for each resident should be consistent with documented treatment preferences and/or advance directives. R94 was admitted with a diagnosis that included malignant neoplasm of the tongue, and the quarterly MDS documented a BIMS score of 15, indicating little to no cognitive impairment. The care plan reviewed for R94 included an Advance Directives focus, but the goal stated that the facility would honor the resident’s wishes and perform CPR in the event of a medical emergency. The physician’s orders also documented DNR, and the SSD confirmed that she was responsible for updating the Advance Directives care plan. During interviews, the MDS Director, SSD, Nurse Manager, and DON all acknowledged that the care plan contained a conflict between the DNR status and the stated goal to perform CPR. The SSD stated the issue was human error and an oversight, and the DON stated that if the care plan goal said to perform CPR while the focus stated DNR, nursing staff would try to determine whether CPR was to be done, which could delay care.
Failure to Supervise a Resident at Risk for Falls
Penalty
Summary
The facility failed to provide supervision to prevent falls for one resident, R125, who was reviewed as part of a sample of five residents with falls and accidents. R125 was admitted with diagnoses including medically complex conditions, non-Alzheimer's dementia, and macular degeneration. The quarterly MDS showed a BIMS score of 00, indicating severe cognitive impairment, and functional status findings showed the resident required extensive assistance with ADLs, including one/two or more-person assistance in multiple areas and use of a wheelchair. The care plan identified R125 as at risk for falls due to impaired mobility, impaired cognitive function, and psychotropic medication use, with interventions including staff assistance to and from the dining room and locking wheelchair brakes when the wheelchair was not in use. The care plan also identified R125 as an elopement risk/wanderer related to dementia and wandering aimlessly, with interventions including structured activities, reorientation strategies, and a wander alert bracelet on the right wrist. During observation, staff assisted R125 to the nurse's station area and locked the wheelchair, but later R125 was observed trying to move the locked wheelchair in order to ambulate, shuffling it to the left and attempting to unlock it before stopping in confusion. In interview, an LPN stated she does not lock the resident's wheelchair because he should have free will, and said she had seen him scoot in the wheelchair when the wheel is locked; she added that the wheelchair would be locked if the resident or family asked for it or if it was care planned.
Unsecured medication cart and unlabeled glucometer strips
Penalty
Summary
The facility failed to record an open date on one bottle of blood sugar strips in one medication cart and failed to lock one medication cart out of six reviewed for medication storage. During observation, one medication cart outside of a resident room was found unlocked and unattended, with no nurse visible anywhere along the hall at that time. Review of the facility’s policies titled Storage of Medications and Medication Administration showed that medication carts and other compartments containing drugs and biologicals are to be locked when not in use and that staff are to maintain security of the cart and keys at all times. During review of the Cedar cart medication cart, one bottle of glucometer strips was found in the top drawer with no open date. The Unit Manager confirmed the bottle should have an open date because the strips lose effectiveness after a certain time and without an open date no one would know when to discard them. An LPN stated blood sugar strips should have open dates because there is a certain time frame they are good for use, and without one no one would know when to throw them out. The DON stated it was her expectation that medication carts be locked when not in use and that blood sugar strip bottles must have open dates.
Inadequate Surety Bond Coverage for Resident Trust Funds
Penalty
Summary
The facility failed to maintain a Surety Bond in an adequate amount to cover the resident trust fund account balance for six consecutive months. The Surety Bond was set at $85,207.06, while the resident trust fund account balances exceeded this amount each month from August 2024 to January 2025, with balances ranging from $107,015.20 to $144,539.69. This discrepancy was identified through staff interviews, record reviews, and a review of the facility's policy on Patient/Resident Trust Funds. The Administrator confirmed that the Surety Bond amount was insufficient compared to the resident trust fund balances and acknowledged being unaware of this issue. The facility's policy required all resident trust fund money, except for petty cash, to be maintained in an interest-bearing checking account. The deficiency had the potential to adversely affect the finances of 84 residents with trust fund accounts managed by the facility.
Expired Medications Found in Storage Rooms
Penalty
Summary
The facility failed to ensure that there were no expired medications in two of its medication storage rooms, which could potentially place residents at risk of receiving expired medications. During an observation of the Gardenia Hall medication storage room, it was found that there were three containers of mineral oil lubricant laxative, three containers of iron supplement liquid, and two containers of arthritis relief, all of which were expired. The Licensed Practical Nurse (LPN) present confirmed the expiration and discarded the expired drugs. In a separate observation of the Sunnyville Hall medication storage room, three containers of Geri Lanta were found to be expired. The Registered Nurse (RN) confirmed the expired medication and discarded it. The RN expressed uncertainty about why the expired medication was present in the storage room and mentioned that nurses randomly checked medication expiration dates. The Director of Nursing (DON) stated that nurses were instructed to check expiration dates when retrieving medications from storage rooms.
Failure to Maintain Resident Dignity with Uncovered Catheter Bag
Penalty
Summary
The facility failed to maintain and protect the dignity of a resident with an indwelling urinary catheter. The facility's policy on catheter care mandates that catheter drainage bags be covered at all times to ensure privacy and dignity. However, observations revealed that the resident's catheter drainage bag was not in a privacy bag and was visible from the hallway, compromising the resident's privacy. The resident expressed concerns about the lack of privacy, and a Licensed Practical Nurse acknowledged that the catheter should have been covered. The resident, who had recently transferred from a personal care home, had a medical history including hemiplegia, hemiparesis, major depressive disorder, generalized anxiety disorder, and a history of urinary tract infections. The resident was dependent on assistance for activities of daily living. A Certified Nursing Assistant confirmed that the catheter drainage bag had been uncovered before she replaced it. The Director of Nursing admitted that the staff had forgotten to cover the catheter bag after the resident's return to the facility.
Failure to Assess Resident for Safe Medication Self-Administration
Penalty
Summary
The facility failed to ensure that a resident, identified as R55, was assessed for safe medication self-administration before allowing medications to be stored at the bedside. The facility's policy requires that a licensed nurse and physician determine the safety of self-administration for each resident. However, R55's electronic medical record showed no documentation of an evaluation for self-administration of medications, and there were no physician orders or care plan interventions for medication self-administration. Despite this, observations revealed that R55 had a container of diclofenac sodium cream and sore throat spray at the bedside, which were not authorized for bedside storage. Interviews with facility staff, including a CNA and the Unit Manager, revealed that they were unaware of the medications in R55's room. The Director of Nursing confirmed that the facility does not allow self-administration of medications without a physician's order and assessment by the interdisciplinary team. The DON acknowledged that unauthorized medications should be removed and that education should be provided to the resident and family. This oversight in monitoring and assessing the resident's ability to self-administer medications led to the deficiency.
Failure to Conduct Pre-Employment Background Checks
Penalty
Summary
The facility failed to conduct pre-employment screenings, specifically background checks and fingerprinting, for two employees, the Director of Nursing (DON) and the Dietary Manager (DM). The facility's policy on Abuse, Neglect, and Misappropriations, effective February 1, 2024, mandates that criminal background checks be conducted prior to permanent employment. However, upon review, it was found that the DON, hired on February 22, 2023, and the DM, hired on February 7, 2023, did not have the required background checks and fingerprints completed. This oversight was confirmed by the facility's Employee Roster Georgia Criminal History Check System (GCHEXS) report, which did not list the DON or DM. Interviews with the Human Resources/Payroll Manager and the Administrator revealed that the corporate office was aware of the missing background checks and fingerprints. The Administrator acknowledged an issue with the system in retrieving these checks and confirmed the absence of the required documentation. Despite the lack of background checks, there were no concerns identified related to abuse or neglect within the facility during the survey. The Administrator also noted that the facility's HR Manager had recently left employment, which contributed to the inability to locate the necessary reports.
Lack of Comprehensive Care Plan for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to ensure that a resident with an indwelling urinary catheter had a person-centered comprehensive care plan for its use. The facility's policy requires a comprehensive care plan to be developed after the completion of the resident assessment (MDS). However, a review of the resident's care plan revealed no care area or interventions for the indwelling urinary catheter. The resident's medical record included diagnoses such as hemiplegia, hemiparesis, major depressive disorder, generalized anxiety disorder, and a history of urinary tract infections. Despite these conditions, the care plan dated 2/14/2025 did not address the catheter. During an interview, the MDS Coordinator confirmed the absence of care areas or interventions for the catheter, attributing the oversight to the resident's initial admission for respite care, where the catheter was not prioritized.
Lack of Qualifying Diagnosis for Indwelling Catheter Use
Penalty
Summary
The facility failed to ensure that a resident with an indwelling urinary catheter had a qualifying medical diagnosis for its use. The resident, identified as R475, had an electronic medical record with diagnoses including hemiplegia, hemiparesis, major depressive disorder, generalized anxiety disorder, and a personal history of urinary tract infections. However, the Admission Minimum Data Set did not include any genitourinary diagnoses, and the Physician's Orders indicated the catheter was for a diagnosis/history of wounds, which was not clinically qualifying. The Director of Nursing confirmed the lack of a qualifying diagnosis for the catheter use, acknowledging the deficiency.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a rate of 10.34 percent during the observation of medication administration for two residents. The errors involved incorrect dosages and formulations of medications administered by an LPN. Specifically, one resident was prescribed divalproex sodium oral capsule delayed release sprinkle 125 mg, four capsules by mouth once daily, but was only given one capsule. Another resident was prescribed vitamin B12 oral tablet extended release 1000 mcg and calcium carbonate 600 mg oral tablet, but received vitamin B12 regular release and calcium carbonate 500 mg instead. The LPN involved confirmed the discrepancies between the administered medications and the physician's orders. The Director of Nursing acknowledged that the LPN was new and required additional training. The facility's policy on medication administration emphasizes the importance of following physician's orders and accepted standards of practice to ensure a safe and effective medication administration process. These errors had the potential to place the residents at risk of medical complications and decreased therapeutic effects of their medications.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to adhere to its infection prevention and control policies during the care of three residents, leading to potential exposure to infections. In the case of a resident requiring fingerstick blood sugar (FSBS) tests, an LPN did not sanitize her hands between glove changes while performing the procedure. This was contrary to the facility's hand hygiene policy, which mandates handwashing between resident contact and after glove removal. The Infection Control Nurse and the Director of Nurses both confirmed that the expected procedure was not followed. Another deficiency was observed during wound care for a resident, where the Wound Care Nurse placed a tray of supplies on the resident's bedside table without sanitizing the surface or using a barrier. After completing the wound care, the tray was placed on the treatment cart without cleaning or using a barrier. Additionally, a resident receiving tube feeding had an unbagged and unlabeled catheter tip syringe on the bedside table, which was not stored or disposed of properly. The DON confirmed that enteral feeding syringes should be labeled, bagged, and properly stored or discarded after use.
Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to notify the Ombudsman regarding the discharge of six residents, as required by their policy. The policy mandates that the Ombudsman be informed of resident discharges, including emergency transfers, either immediately or in a monthly list. However, the facility did not adhere to this requirement for any of the six residents reviewed, resulting in a deficiency. For each of the six residents, there was no documentation in their electronic medical records indicating that the Ombudsman was notified of their discharge. These residents were either transferred to a hospital and did not return or were discharged to other care settings, such as hospice. The facility's policy on transfer and discharge, which includes notifying the Ombudsman, was not followed, as evidenced by the lack of documentation and the Social Service Director's admission of being unaware of the requirement. Interviews with facility staff revealed a lack of awareness regarding the necessity of notifying the Ombudsman about resident discharges. The Social Service Director stated she was unaware of this requirement, and the Administrator confirmed that the Ombudsman had not been notified of discharges. This oversight led to the facility's failure to comply with its own policy and regulatory requirements, resulting in the identified deficiency.
Infection Control Deficiency in Glucometer Use
Penalty
Summary
The facility failed to adhere to its infection control process, specifically in the disinfection of glucometers used for blood glucose testing. Observations revealed that two out of three nurses did not follow the established protocol for cleaning and disinfecting glucometers after each use. The facility's policy, dated November 2017, clearly states that glucometers should be cleaned and disinfected after each use according to the manufacturer's instructions, regardless of whether they are intended for single or multiple resident use. However, during observations, it was noted that the nurses placed the glucometers on surfaces without using a barrier and did not clean the devices with a sanitizing wipe before storing them back in the medication cart. The first incident involved an LPN who placed the glucometer on the medication cart and the resident's overbed table without a barrier and failed to clean it after use. Similarly, the second LPN placed the glucometer and supplies on the medication cart and overbed table without a barrier and did not sanitize the surfaces. Both nurses acknowledged the need for a barrier and cleaning, but did not follow through with the required procedures. The Director of Nursing confirmed that the glucometers should be cleaned with a germicidal disposable wipe after each use and that a barrier must be used when placing the glucometer and supplies on any surface.
Failure to Provide Quarterly Trust Fund Statements
Penalty
Summary
The facility failed to provide quarterly statements for resident trust fund accounts to three residents, R4, R6, and R9, out of 100 residents with such accounts managed by the facility. The facility's policy, dated February 1, 2024, requires that residents receive quarterly statements at the end of each calendar quarter. However, interviews with the residents revealed that they had not received these statements. R6 reported not receiving a statement since February 2024, and R9 stated he did not know the balance of his account due to not receiving statements. R4 also confirmed not receiving a quarterly statement and relied on the front office for balance inquiries. The Business Office Manager (BOM) acknowledged managing the residents' trust fund accounts and stated that the statements were prepared and given to the Receptionist and Activities Director for distribution. However, the BOM admitted it was ultimately her office's responsibility to ensure the residents received their statements. Despite the procedure in place, the residents did not receive their quarterly statements, indicating a lapse in the distribution process. This deficiency had the potential to affect all residents with trust fund accounts managed by the facility.
Failure to File Resident Grievances Promptly
Penalty
Summary
The facility failed to promptly file grievances for two residents who verbally reported their concerns, as required by their grievance policy. One resident, who was cognitively intact, expressed concerns during a resident council meeting about the lack of nebulizers and the failure to receive medications at night. However, there was no documented grievance filed for this resident in the grievance log for the month. Another resident, also cognitively intact, reported issues with dirty washcloths, foul-smelling laundry, and a missing wallet during a resident council meeting. Despite these concerns, no grievance was documented for this resident either. Interviews with staff revealed that the Social Service Director (SSD) was responsible for tracking grievances, and grievances could be verbal or written. The SSD stated that grievances should be resolved within three days. The Activities Director mentioned that concerns raised during resident council meetings should be addressed immediately by the relevant department head or documented if the department head was unavailable. However, the SSD confirmed that no grievances were filed for the two residents in question, indicating a failure to adhere to the facility's grievance policy.
Latest citations in Georgia
Surveyors found that clean linens and personal clothing were stored and staged in close proximity to the dirty laundry area, with an open door between the clean and soiled sides and all washer and dryer doors open. Clean resident clothes, unlabeled garments, and bagged items were placed next to dryers and directly in front of the dirty linen room, and dirty barrels had to be pushed past racks of clean clothing to reach the washers, contrary to facility policies requiring separation of clean and soiled linens. Environmental staff believed keeping doors open and covering dirty barrels reduced infection spread, while the Environmental Services Director, IP nurse, and Administrator acknowledged that the dirty room door should be closed, linens should not be on dirty barrels, and clean resident clothing should not be stored in that location.
A resident with a suprapubic catheter, colostomy, sacral wound, and dependence on staff for bathing and hygiene was care planned for Enhanced Barrier Precautions (EBP), including use of PPE during high-contact care. During observed catheter care and a bed bath, a CNA wore only gloves and did not don a gown, despite EBP signage and a star posted on the door and PPE supplies available outside the room. In interviews, the CNA admitted forgetting to wear a gown and not recognizing additional required actions, while the IP nurse and DON confirmed that staff had been educated that gowns and gloves are required for high-contact care involving indwelling devices and wounds under the facility’s EBP policy.
A resident with multiple neurologic and psychiatric diagnoses, intact cognition, and unilateral functional limitations was found with an open box of lubricant eye drops stored at the bedside without any documented assessment for self-administration or prescriber’s order for self-administration or bedside storage, contrary to facility policy. Observations on multiple days confirmed the eye drops remained at the bedside, while staff interviews showed that CNAs and the IP recognized that residents were generally not to self-administer medications and that bedside medications required assessment and orders. The Administrator confirmed that the resident should not have had eye drops in the room and that residents with bedside medications are typically assessed for self-administration, and staff acknowledged that unsecured eye drops at the bedside could be accessed or ingested by other residents and cause harm.
The facility failed to maintain a safe, clean environment when multiple ceiling tiles throughout the building, including above a resident’s bed, near the nurses’ station, in a glass day room above a resident’s chair, and in a main hall, were observed with brown circular stains, bulging, and a white moldy substance. The Maintenance Director confirmed the stained and bulging tiles, acknowledged the risk that tiles above a resident’s bed could fall, and attributed the condition to rain-related roof leaks. The Administrator also confirmed that roof leaks and recent rainfall caused the brownish stains despite her reported daily rounds.
A resident with severe cognitive impairment, on hospice and fully dependent for ADLs, was sexually abused when another cognitively impaired male resident with a long-standing history of sexually inappropriate behavior toward female residents entered her room and placed his hand inside her pants. The abusing resident had multiple dementia and psychiatric diagnoses, was care planned for sexually inappropriate behaviors with prior documented incidents, and was on psychotropic medication for OCD-related sexual obsession. Despite these known risks and existing care plan interventions, he was able to access the female resident’s room and make inappropriate physical contact, and the facility’s investigation substantiated the abuse.
Surveyors found that the facility failed to develop and implement complete, person-centered care plans for two residents. One resident was receiving an antipsychotic (Haloperidol) for schizophrenia with associated behavior and side-effect monitoring orders, but there was no corresponding care plan addressing antipsychotic use or its indication. Another resident had an indwelling Foley catheter for neurogenic bladder related to prostate cancer, with goals to prevent catheter-related trauma; however, the care plan omitted key interventions such as balloon volume parameters and use of a leg strap or securement device, despite physician orders requiring a leg strap and observations showing the catheter positioned under the leg without securement. An MDS coordinator and the administrator acknowledged that required interventions and standard catheter care components were missing from the care plans.
A resident with a history of resistiveness to care and noncompliance with the non‑smoking policy had a comprehensive care plan that was not updated to reflect multiple interventions implemented in response to repeated smoking and vaping violations. Although the care plan noted the need for supervision while smoking and review of the smoking policy, it did not include measures such as daily room searches for smoking materials, added smoke detection in the room, relocation closer to the nurses’ station, q2h visual rounds for smoke, post‑outing nursing checks, initiation of a PAR process for vaping, or issuance of a discharge notice. Facility forms showed inconsistent documentation of daily room searches and incomplete IDT documentation on the PAR tracking, despite multiple documented episodes of policy violations and removal of vaping devices.
A cognitively intact but physically impaired resident with a history of noncompliance with the facility’s non‑smoking policy repeatedly smoked and vaped in his room while keeping multiple vape devices and other items at bedside. The facility’s Smoking Policy required that non‑compliant smokers have daily documented searches and be prohibited from keeping smoking materials in their rooms, yet monitoring forms showed many days without documented searches, Patient at Risk tracking was incomplete, and staff acknowledged that daily room checks and frequent rounds were not consistently performed. Multiple staff, including a CNA, social worker, Infection Preventionist, MDS coordinator, Activities Director, and the Administrator, reported ongoing violations and repeated discovery of vape devices in the resident’s room, including during surveyor observations, demonstrating that the environment was not maintained free from accident hazards and that required supervision and monitoring were not reliably implemented.
Surveyors found that a treatment cart containing topical medications was left unlocked and unattended in a hall across from a resident’s room after wound care was completed by an LPN. The facility’s policy requires that medication carts and supplies be locked or attended and accessible only to licensed or otherwise authorized staff. During interviews, the LPN confirmed the cart had been left unlocked and unattended, the IP LPN confirmed the LPN’s report that the cart was left unlocked, and the Administrator stated that all medications, including topical medications, were expected to be locked when not in sight of authorized staff.
The facility failed to implement its infection prevention and control program by not operationalizing a documented Legionella water management plan despite having a written policy, and by not fully implementing Enhanced Barrier Precautions (EBP) for residents with indwelling devices and other risks. A resident with an indwelling urinary catheter had no EBP care plan or orders, no EBP signage, and staff providing catheter care wore only gloves without gowns, while multiple staff members reported not knowing what EBP was or misidentified who should be on EBP. Another resident receiving tube feeding had care initiated by an LPN who wore gloves but no gown and repeatedly touched her hair with the same gloved hands before handling the feeding tube and equipment, later acknowledging she should have changed gloves and was unaware of EBP requirements, even though other clinical staff stated gowns and gloves should be used for feeding tube care. A resident on isolation for C. diff had a door sign indicating isolation but no instructions for visitors on required PPE or to seek staff guidance, and the IP confirmed there was no system to direct visitors about precautions, contributing to the overall infection control deficiency.
Failure to Maintain Separation of Clean and Soiled Laundry
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to separation of clean and soiled linens. Facility policies titled “Infection Prevention and Control Program” and “Handling Soiled Linens” required that clean linen always be separated from soiled linen. During an observation of the laundry area, all washer and dryer doors were open in the clean linen area. Clean linens, including sheets, towels, blankets, and washcloths, were folded on a table to the left of the washer and dryer room. On the right side of the room, next to the dryers and directly in front of the open door to the dirty laundry room, there were residents’ clean clothes on a rack, piles of folded clean clothes to be hung, a rack of unlabeled clothes, and a bag of unlabeled clothes. Dirty laundry barrels had to be pushed past the clean clothing on the racks to reach the washers, placing soiled items in close proximity to clean items despite policy requirements for separation. Environmental staff working in the laundry stated they believed they were reducing the spread of infection by keeping all doors open, covering dirty barrels, and circulating air, and they explained that the uncovered rack and bagged clothes near the dirty area were no-name clothes sometimes distributed to residents in need. They also stated that the rack of clean personal resident clothing parked in front of the open dirty linen room door was awaiting distribution by a staff member who worked only at night. The Environmental Services Director reported that the door to the dirty side of the laundry should always be closed and that no linen should be on top of dirty barrels. The Infection Preventionist nurse, when shown pictures and concerns about cross-contamination, confirmed there was a problem in the laundry but stated she had not been aware of it previously. The Administrator stated that residents’ clothes should not be stored where they were observed and should be handed out immediately once clean, and that she expected the laundry to be organized to prevent cross-contamination between dirty and clean clothes.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff followed its Enhanced Barrier Precautions (EBP) policy for the use of personal protective equipment (PPE) during high-contact care. The facility’s EBP policy, updated February 2025, requires gowns and gloves for residents with wounds and/or indwelling medical devices, including urinary catheters and ostomies, when staff perform high-contact activities such as bathing, dressing, toileting, hygiene, and catheter care. The policy also directs that gowns and gloves be made available near or outside the resident’s room and that EBP be implemented for residents with indwelling devices or wounds, even if they are not known to be infected or colonized with a multidrug-resistant organism. The resident involved had a suprapubic catheter, colostomy, sacral wound, and neurogenic bladder and bowel, and was care planned for EBP implementation during catheter and skin care. The resident was cognitively intact but dependent on staff for bathing, dressing, toileting, hygiene, bed mobility, and transfers, and used an indwelling catheter and ostomy. During an observation, a CNA provided suprapubic catheter care and a bed bath to this resident while only wearing gloves, despite EBP signage and a star posted on the door and PPE supplies available outside the room. The CNA did not don a gown and was unable to identify any additional actions needed before care until prompted about the EBP signage, at which point he acknowledged he should have worn a gown but forgot. In a subsequent interview, the IP nurse and DON confirmed that staff had been educated that gowns are required during high-contact care for residents with catheters, colostomies, and other devices, and that the posted signage and star were intended to alert staff to the need for enhanced PPE use.
Failure to Assess and Obtain Orders for Self-Administration and Bedside Medication Storage
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policies for self-administration of medications and bedside medication storage for one resident. The facility’s policies require that residents who wish to self-administer medications must be assessed by the interdisciplinary team for cognitive, physical, and visual ability, and that a prescriber’s order for self-administration and bedside storage must be present in the medical record and reflected on the MAR and medication label. For the resident in question, who had diagnoses including cerebral infarction, major depressive disorder with psychotic symptoms, PTSD, hemiplegia and hemiparesis, speech and language deficits, and cerebral atherosclerosis, the EHR showed no assessment for self-administration and no physician order for self-administration or bedside storage, despite active ophthalmic medication orders. The resident’s MDS documented intact cognition with a BIMS score of 15, use of corrective lenses, and functional limitations in range of motion on one side of both upper and lower extremities. Surveyor observations on two consecutive days found an open box of lubricant eye drops on the resident’s bedside table. Staff interviews revealed inconsistent understanding and enforcement of the facility’s policies. A CNA stated that residents did not self-administer medications and that only nurses administered them, but also reported that when she previously reported the eye drops, she was told the resident could have them because he was independent. The Infection Preventionist acknowledged the resident had an order for eye drops and believed he obtained them from the VA, and stated he should not have the lubricant eye drops because they were a hazard for other people. The Administrator confirmed that typically a resident with medications at the bedside should be assessed for self-administration and stated the resident should not have eye drops in his room. The report notes that unsecured medications at the bedside had the potential to cause adverse reactions if accessed or ingested by other residents.
Failure to Maintain Safe and Clean Ceiling Surfaces Throughout Facility
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable homelike environment as required by its Maintenance Service policy, which assigns the Maintenance Department responsibility for keeping the building in good repair and free from hazards. Surveyors observed multiple stained and damaged ceiling tiles in several areas of the facility, including near the nurses' station, in a resident bedroom (room [ROOM NUMBER]A), in the glass day room, and in the middle of the east hall. On several occasions, ceiling tiles near the nurses' station were noted to have tannish-brown circular stains of varying sizes, and at one point a white, moldy substance was observed on a ceiling tile in that same area. In room [ROOM NUMBER]A, surveyors observed brown rings roughly 16 inches in diameter on ceiling tiles located directly above a resident’s bed, with the Maintenance Director later confirming that these tiles were stained, bulging, and at risk of falling on the resident. Additional observations in the glass day room identified two stained ceiling tiles above a resident’s chair, each with brown circular stains approximately three inches in diameter. In the east hall, a ceiling tile with a brown circular stain approximately 10 inches in diameter was also documented. The Maintenance Director and the Administrator both acknowledged that the stains and damage were related to roof leaks associated with recent rainfall, and the Administrator confirmed awareness of roof leaks that had previously been repaired and that the brownish stains were due to recent rain.
Failure to Prevent Sexual Abuse of a Cognitively Impaired Resident by Another Resident
Penalty
Summary
The facility failed to protect a dependent, cognitively impaired resident (R113) from sexual abuse by another resident (R12). R113 had severe cognitive impairment with a BIMS score of 5, was on hospice care, and was fully dependent for toileting, bathing, dressing, footwear, and personal hygiene. On the day of the incident, a CNA observed R12 in R113’s room with his right hand inside R113’s pants while she was seated in a geriatric chair. Staff witness statements and nursing progress notes documented that R12 was found in R113’s room with his hand in her pants, and the facility’s investigation substantiated that R12 touched R113 inappropriately. R12 also had severe cognitive impairment with a BIMS score of 4 and multiple psychiatric and dementia-related diagnoses, including vascular dementia with mood disturbance, Alzheimer’s disease, major depressive disorder, obsessive-compulsive personality disorder, unspecified psychosis, and unspecified mood affective disorder. He required extensive physical assistance, used a manual wheelchair, and was fully dependent for toileting, bathing, lower body dressing, and footwear. R12’s care plan, in place since 2017, identified him as having sexually verbally and physically inappropriate behavior, including documented prior incidents in which he inappropriately touched or attempted to touch female residents. His care plan included interventions such as discussing his behavior when reasonable, explaining that it was inappropriate, intervening to protect others, diverting his attention, and removing him from situations as needed, as well as monitoring and recording occurrences of target behaviors such as sexual aggression toward others. Despite this known history of sexually inappropriate behavior toward female residents and the presence of care plan interventions, R12 was able to enter R113’s room and place his hand inside her pants. The Administrator confirmed that the CNA reported finding R12 in R113’s room with his hand in her pants while R113 was in her wheelchair, and that the facility’s investigation substantiated the abuse allegation. The facility’s abuse policy stated that it would not condone resident abuse by anyone, including other residents, and defined sexual abuse to include sexual harassment, sexual coercion, or sexual assault. The occurrence of this incident demonstrated that the facility did not effectively prevent sexual abuse of R113 by another resident, despite R12’s documented behavioral history and existing care plan.
Failure to Develop and Implement Complete Care Plans for Antipsychotic Use and Foley Catheter Management
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for identified resident needs, as required by its Comprehensive Care Plan policy. The policy states that care plans must address all needs identified in the comprehensive assessment, including medical, nursing, mental, and psychosocial needs, and must be developed within seven days after completion of the comprehensive MDS assessment. It also requires that all triggered Care Area Assessments (CAAs) and other factors identified by the IDT or resident preferences be incorporated into the plan of care. For one resident, R44, the clinical record showed physician orders for Haloperidol 10 mg by mouth twice daily for schizophrenia, along with orders for behavior monitoring and psychiatric medication side effect monitoring. Despite these orders, the resident’s care plan dated 03/11/2026 did not include any care plan addressing antipsychotic medication use or its indication. The MDS Coordinator stated that all residents receiving antipsychotic treatment should have a comprehensive care plan in place beginning with the date the medication was originally ordered, and upon review of the record confirmed that such a care plan was not present for this resident at the time of the survey. For another resident, R3, the care plan dated 03/13/2026 identified a problem of an indwelling catheter secondary to neurogenic bladder related to prostate cancer, with goals including remaining free from catheter-related trauma. The listed interventions included positioning the catheter bag and tubing below bladder level, monitoring and documenting intake and output per policy, and monitoring for pain, discomfort, and signs and symptoms of UTI. However, the care plan did not address the amount of water in the catheter balloon, use of a leg strap or securement device, or other securement measures. Physician orders specified checking a leg strap every shift and documented that the resident was admitted with an 18F catheter attached to a bedside drainage bag, but observations showed the Foley catheter positioned under the resident’s leg without a leg strap or securement device on two occasions, and a CNA reported being unaware that a leg strap was required. The MDS Coordinator confirmed that these ordered interventions were missing from the care plan.
Failure to Revise Care Plan for Ongoing Smoking Policy Noncompliance
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive care plan to reflect current interventions implemented in response to ongoing noncompliance with the facility’s non‑smoking policy. The facility’s policy requires that the comprehensive care plan be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment, and that it include measurable objectives, timeframes, and alternative interventions as needed, with qualified staff notified when changes are made. The resident’s care plan included a focus on resistiveness to care and noncompliance with smoking, noting that the resident continued to go outside beyond facility property to smoke, and an intervention to review the smoking policy with the resident. Another care plan focus identified the resident as a smoker requiring supervision while smoking, with interventions stating the resident required supervision while smoking and that the charge nurse should be notified if a smoking policy violation was suspected. Despite repeated and ongoing noncompliance with the non‑smoking policy, the care plan was not revised to include additional interventions that were actually implemented. These unreflected interventions included daily room searches for smoking paraphernalia, placement of a smoke detector in the resident’s room, relocation of the resident’s room closer to the nursing station, every‑two‑hour visual rounds to check for smoke, nursing checks upon return from outings, initiation of a Patient at Risk (PAR) process for vaping noncompliance, and issuance of a 30‑day discharge notice for repeated violations of the non‑smoking policy. Documentation on the Smoking Materials Monitoring Form showed initials on selected days only, indicating daily room searches were not consistently completed and documented for the entire month. The PAR Smoking Tracking form documented multiple observations of vaping in the room, repeated room checks, removal of vapor devices, and the resident’s refusal to comply with facility policies, with later weeks lacking IDT signatures and documentation, while the PAR Grid showed multiple prior entries for violating the non‑smoking policy.
Failure to Control Smoking and Vaping Hazards for a Noncompliant Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision for a resident with a known history of noncompliance with the facility’s non‑smoking policy. The facility’s Smoking Policy requires that residents not be allowed to keep cigarettes, cigars, pipes, matches, or lighters in their possession or rooms, and that non‑compliant smokers receive daily searches with documentation, while compliant smokers receive weekly searches. The policy also requires incident reports and review in a “Patients at Risk” process whenever smoking materials are found. Despite these written procedures, the resident’s Smoking Materials Monitoring Form for April showed multiple days without documented searches, indicating that required daily room searches were not consistently completed or recorded. The resident at issue was cognitively intact, with a BIMS score of 15, and had significant physical impairments including hemiplegia and hemiparesis on the left side, use of a manual wheelchair, and other neurologic and psychiatric diagnoses such as cerebral aneurysm, cerebral infarction, major depressive disorder with psychotic symptoms, PTSD, and speech and language deficits. The care plan identified the resident as resistive to care and noncompliant with smoking, noting that he continued to go outside beyond facility property to smoke, and also identified him as a smoker requiring supervision while smoking. Progress notes and Patient at Risk documentation showed a pattern of repeated violations of the non‑smoking policy, including multiple instances of vaping and smoking in his room, with staff repeatedly finding vape devices and other smoking paraphernalia in his possession and in his room. Throughout the period reviewed, staff observations and interviews confirmed ongoing noncompliance with the smoking policy and inconsistent implementation of the facility’s own interventions. Staff documented several occasions when the resident was observed vaping or smoking in his room, including in the presence of a state surveyor, and room searches revealed multiple vape devices hidden under the sheets. Staff interviews indicated that daily room checks were not always performed due to competing demands, that logs of every‑two‑hour rounds were not maintained, and that there was confusion or inconsistency regarding whether the resident could keep items such as air freshener at bedside. The social worker, Infection Preventionist, MDS coordinator, Activities Director, CNA, and Administrator all acknowledged that the resident’s room had to be searched for cigarettes and vaping paraphernalia and that prohibited items were repeatedly found, while documentation showed gaps in the required daily searches and incomplete follow‑through on the Patient at Risk tracking process. These actions and inactions resulted in the environment not being kept free from accident hazards as required by the facility’s policy and regulatory standards. The deficiency is further supported by the facility’s own records showing repeated entries on the Patient at Risk grid for violations of the non‑smoking policy over an extended period, as well as narrative notes describing the resident’s statements that he would continue to vape in his room and would simply obtain new devices if they were confiscated. Despite the known pattern of behavior and the facility’s policy requiring close supervision, daily searches, and thorough documentation for non‑compliant smokers, the monitoring forms and staff interviews demonstrate that these measures were not consistently carried out. The presence of multiple vape devices and cans of air freshener at the bedside during surveyor observations, along with staff acknowledgment that room checks were missed and that logs of frequent rounds were not kept, illustrate the facility’s failure to effectively implement its own safety procedures to prevent accident hazards related to smoking and vaping in the resident’s room.
Unlocked and Unattended Treatment Cart with Topical Medications
Penalty
Summary
Surveyors identified a deficiency related to medication storage when a treatment cart containing topical medications was left unlocked and unattended in a hall. The facility’s policy titled “Medication Storage in the Facility,” effective 10/01/2025, states that the medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff lawfully authorized to administer medications, and that medication rooms, carts, and supplies are to be locked or attended by authorized personnel. During an observation on 04/29/2026 at 9:35 AM, after wound care was provided to resident R3 by the wound care LPN, the treatment cart was observed left in the [NAME] hall across from R3’s room, unlocked and unattended for 30 minutes. In an interview, the wound care LPN confirmed that the treatment cart had been left unlocked and unattended. The Infection Preventionist LPN later confirmed that the wound care nurse told her the cart was left unlocked, and the Administrator stated that her expectation was that all medications, including topical medications, be locked when not in sight of a licensed nurse or authorized person. This deficient practice occurred in a facility with a census of 94 residents and involved the failure to follow the facility’s own policy requiring that medication carts be locked or attended by authorized personnel, resulting in unsecured access to topical medications on the treatment cart.
Failure to Implement Legionella Water Management and Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to provide and implement an infection prevention and control program, including a documented water management plan for Legionella and other waterborne pathogens, and a fully implemented Enhanced Barrier Precautions (EBP) program. The Administrator stated there was no Legionella water program in place, and the Maintenance Supervisor reported he was unaware of the requirement for such a program. This was despite the existence of a written Legionella Water Management Program policy, revised in September 2022, which described the need for an interdisciplinary water management team, detailed water system diagrams, identification of risk areas and situations for Legionella growth, control measures, monitoring systems, and annual review. Interviews confirmed that the expectation was that the facility would be conducting this water program, but it was not being done. The facility also failed to implement EBP for residents with indwelling medical devices and other risk factors, as required by its own policy. One resident with Alzheimer’s disease, urinary obstruction, and emphysema had an indwelling urinary catheter documented in the care plan and physician orders, but the care plan did not address EBP related to the catheter, and there was no order for EBP in the record. During catheter-related care, a CNA wore gloves but did not wear a gown, and there was no EBP signage or PPE setup at the room. Multiple staff members, including CNAs and a housekeeper who regularly worked on the resident’s hallway, reported they did not know what EBP was or incorrectly associated EBP only with residents on Transmission-Based Precautions. The DON acknowledged that an attempt to roll out EBP months earlier had not been completed, and that expected signage and PPE caddies for EBP were not fully in place. Additional infection control lapses were observed during tube feeding care and contact isolation. A resident receiving continuous tube feeding had a care plan and physician’s order for enteral nutrition, and an LPN initiated the feeding while wearing gloves but no gown. During the procedure, the LPN repeatedly touched her hair with the same gloved hands and then handled the feeding tube, pump, and syringe used to inject air and check residuals, only removing gloves and using hand sanitizer at the end. The LPN later acknowledged she should have changed gloves after touching her hair and stated she did not know what EBP was or that a gown was required for feeding tube care, while another LPN and the IP stated that EBP with gown and gloves should be used for feeding tube care and that staff should not touch their hair during care without changing gloves and performing hand hygiene. For a resident with a positive urine culture and a subsequent positive C. difficile culture who was on isolation, the door sign indicated isolation but did not provide instructions for visitors on required precautions or direct them to staff for guidance. The IP confirmed there was no system to direct visitors about PPE use for residents on contact isolation and acknowledged that visitors would not know to wear PPE if it was simply present in or on the door of the room. Overall, the survey findings show that the facility did not operationalize its written Legionella water management policy and did not consistently apply its EBP policy for residents with indwelling devices or wounds. Staff interviews and observations demonstrated a lack of knowledge and implementation of EBP, incomplete use of PPE during high-contact care activities such as catheter care and tube feeding, and unclear isolation signage that did not instruct visitors on appropriate precautions. These combined inactions and omissions in policy implementation, staff education, and practice led to the cited infection prevention and control deficiency.
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