Thomasville Vistas Of Journey Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Thomasville, Georgia.
- Location
- 120 Skyline Drive, Thomasville, Georgia 31757
- CMS Provider Number
- 115427
- Inspections on file
- 17
- Latest survey
- December 19, 2025
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Thomasville Vistas Of Journey Llc during CMS and state inspections, most recent first.
Two residents with documented allergies to fish and shellfish were served meals containing these allergens. One resident was given a crab cake despite a shellfish allergy, realized the error after tasting, and did not experience a reaction. Another resident with a fish allergy reported repeatedly receiving fish and returning it. Staff interviews confirmed that both dietary and nursing staff were responsible for checking meal trays for allergens, but these checks failed to prevent the errors.
Staff did not follow infection control protocols during wound and perineal care for a resident with a pressure ulcer. A CNA and an LPN both provided direct care without wearing protective gowns as required by enhanced barrier precautions, and wound care supplies were placed on an unsanitized bedside table. Staff interviews indicated gowns had not been available for a month, despite being present in the supply room.
A facility failed to obtain ordered lab tests for a resident, leading to actual harm. The resident, with multiple health conditions, had a physician order for a CBC every three months, which was not completed for March and June. In September, a critically low hemoglobin level was discovered, resulting in the resident being hospitalized for iron deficiency anemia and receiving a blood transfusion.
The facility failed to provide full RN coverage for eight hours on multiple occasions due to an automatic time clock deduction for breaks, resulting in discrepancies in the PBJ Staffing Data Report. Despite scheduling efforts, the RNs did not meet the required hours, affecting the facility's compliance with staffing regulations.
The facility failed to follow recipes for pureed carrots and chicken, affecting the nutritional value for residents on a pureed diet. Staff added water during the pureeing process, which was not in the recipe, and used an incorrect scoop size, providing less than the recommended protein portion. Interviews revealed staff were unaware of correct portion sizes and scoop measurements.
The facility failed to properly label and date food items, discard expired foods, and maintain the cleanliness of the ice machine. Observations revealed multiple unlabeled and undated food items, some past expiration, and an ice machine with chalky and black substances. Interviews confirmed lapses in adherence to policies for food handling and ice machine maintenance.
Two residents with indwelling urinary catheters were observed with uncovered catheter bags visible from their rooms, violating the facility's policy on maintaining resident dignity. Despite care plans in place, the catheter bags were not covered, which was confirmed as a dignity issue by nursing staff.
A facility failed to obtain a concurring physician's signature on a DNR order for a resident with severe cognitive impairment and no documented POA or guardian. The DNR was signed by an unauthorized person, and the resident's code status was changed to Full Code. Interviews confirmed the absence of a healthcare agent, and family members stated no legal guardianship existed.
The facility failed to provide a home-like environment, with observations of missing floor tiles, peeling paint, rust on equipment, and persistent odors in resident areas. Staff acknowledged these issues, noting offensive urine odors and rust on toilet seats and shower chairs. The Maintenance Director was unaware of needed repairs.
A facility failed to monitor a resident's dialysis access site and ensure communication with the dialysis center. The resident, with conditions like diabetes and end-stage renal disease, had no orders for site care. Staff interviews and observations confirmed lapses in documentation and communication, with missing or incomplete Dialysis Communication Sheets.
A facility failed to complete and transmit a discharge MDS assessment within 14 days for a resident who was admitted with multiple diagnoses and discharged against medical advice. Interviews revealed no discharge assessment or documentation was completed, contrary to facility policy.
A resident with end-stage renal disease did not receive proper monitoring and documentation for hemodialysis care as outlined in their care plan. The facility's records lacked consistent documentation of ongoing monitoring and communication with the dialysis center. Staff interviews confirmed missing and incomplete dialysis communication sheets, indicating a failure to adhere to the care plan.
An unsecured oxygen cylinder was found on the floor of a resident's room, posing a potential hazard. The resident, diagnosed with acute hypoxemic respiratory failure, was receiving oxygen therapy. Staff interviews revealed a lack of awareness about the danger of an unsecured cylinder, with a housekeeper, LPN, CNA, and RN failing to secure it. The LPN removed the cylinder upon discovery, and the RN expected CNAs to ensure cylinders were secured, indicating a lapse in adherence to safety protocols.
A resident with a history of urinary tract infections and sepsis had an indwelling catheter without a physician's order. The catheter tubing was frequently observed in improper positions, such as coiled, touching the floor, or obstructed by the chair's armrest, potentially impeding urine flow. Staff confirmed the absence of an active order and improper tubing positioning, despite being informed about correct procedures.
A resident receiving oxygen therapy was administered oxygen at a rate below the physician's order, and the facility failed to place required oxygen warning signage on the resident's door. The LPN and RN were unaware of these deficiencies until informed by the surveyor.
A resident with multiple diagnoses, including mood disorder and anxiety, was administered Haloperidol for agitation without prior alternative interventions. Staff interviews revealed the resident was restrained during medication administration, despite not acting out. A recommendation for Ativan as an alternative was not followed, contributing to the deficiency.
A facility failed to report an incident where a resident was allegedly restrained by the DON and LPNs during medication administration, despite the resident not acting out. The resident, with multiple health conditions, was calm and wanted to discuss the confiscation of his vape pen. The incident was not reported to the State Agency due to unfamiliarity with the process, and the Administrator was initially unaware of the situation.
A facility failed to comply with regulations for PRN antipsychotic medications. A resident returned from the ER with a PRN Haldol order, which was extended without a required physician re-evaluation. The resident received Haldol beyond the 14-day limit without proper documentation. A behavioral consultant recommended Ativan and Haldol, but there was no physician documentation for continued PRN use.
A resident with multiple health conditions was not provided with recommended restorative services after being discharged from skilled physical therapy. Communication breakdowns between the Physical Therapy Assistant, LPN, and DON led to a delay in implementing the restorative program, which included ambulation, range of motion, and transfer activities.
Residents Served Meals Containing Documented Allergens
Penalty
Summary
Two residents with documented allergies to fish and shellfish were served meals containing these allergens. One resident, with a history of gastro-esophageal reflux disease and vitamin deficiency, had shellfish listed as an allergy in both the admission record and active orders. Despite this, the resident was served a crab cake, took a bite, and then realized it contained shellfish, prompting her to spit it out and rinse her mouth. The incident was reported by a CNA, and it was confirmed by the Certified Dietary Manager that the resident had received the wrong tray. The resident did not experience an allergic reaction, but the event was documented in the facility's incident report. Another resident, diagnosed with adult failure to thrive and with a documented fish allergy, reported receiving fish every time it was on the menu and consistently sent it back. A CNA confirmed that the resident had been served a meal with fish and that she returned the tray to dietary for a replacement. Staff interviews revealed that both dietary and nursing staff were responsible for checking meal trays for allergens, but these checks failed to prevent the residents from being served foods to which they were allergic.
Failure to Follow Enhanced Barrier Precautions During Wound and Perineal Care
Penalty
Summary
Staff failed to follow infection control protocols during wound care and perineal care for a resident with an unstageable pressure ulcer. Specifically, a Certified Nursing Aide (CNA) provided perineal care and removed a soiled brief without wearing a protective barrier gown, and a Licensed Practical Nurse (LPN) performed wound care on the resident's right heel without donning a gown. Additionally, the LPN placed wound care supplies directly on a bedside table without sanitizing the surface or using a barrier, contrary to facility policy. Interviews revealed that gowns had not been available to staff for the past month, and staff were aware that gowns should be worn during high-contact care activities, especially for residents on enhanced barrier precautions. The Infection Preventionist confirmed that gowns should be used in these situations but was unsure why staff were not wearing them. An observation later confirmed that gowns were present in the supply room, indicating a breakdown in the process of making gowns available to staff at the point of care.
Failure to Obtain Ordered Labs Results in Harm
Penalty
Summary
The facility failed to ensure laboratory orders were obtained as ordered by the physician for a resident, resulting in actual harm. The resident, identified as R21, was admitted to the facility with multiple diagnoses, including idiopathic gout, cerebral infarction, aphasia, hemiplegia, diabetes mellitus, chronic systolic congestive heart failure, hypertensive heart disease, hypercholesterolemia, angina pectoris, major depressive disorder, and epilepsy. A physician order dated March 7, 2023, required the collection of a complete blood count (CBC) with differential every three months in March, June, September, and December. However, the facility did not obtain the ordered labs for March 2023 and June 2023. On September 19, 2023, the facility received lab results indicating that R21 had a critically low hemoglobin level of 5.9 g/dl, significantly below the normal range of 13.5 - 17.5 g/dl. This critical lab result prompted the facility to contact the medical director, who decided to send the resident to the emergency room. The resident was subsequently admitted to the hospital, diagnosed with iron deficiency anemia, and received two units of blood. An interview with the unit manager revealed that the CBC results for March and June 2023 were not completed and could not be located in the electronic laboratory system or the resident's medical record.
Failure to Provide Full RN Coverage
Penalty
Summary
The facility failed to provide Registered Nurse (RN) coverage for a full eight hours within a 24-hour period on multiple dates during the first quarter of 2024. The Payroll-Based Journal (PBJ) Staffing Data Report indicated that there were no RN hours recorded for specific dates, despite the facility's attempts to schedule RN coverage. The Business Office Manager confirmed that the time clock system automatically deducted 30 minutes for lunch, which resulted in the RN not being recorded as working a full eight hours. This issue was acknowledged by the Administrator, who was aware that the discrepancy could trigger a report. The Licensed Practical Nurse (LPN) Unit Manager, responsible for staffing RN coverage, reported that the new time clock system automatically clocks out staff for breaks, regardless of whether they were taken. This led to the RNs not meeting the required eight hours of coverage. The facility's census at the time was 40 residents, and the failure to provide adequate RN coverage was a recurring issue on several dates, as confirmed by the PBJ report and staff interviews.
Failure to Follow Puree Diet Recipes and Portion Sizes
Penalty
Summary
The facility failed to ensure that the recipe for pureed carrots and chicken was followed, which compromised the nutritional value of the food provided to residents on a pureed diet. During an observation, it was noted that a staff member added tap water to the carrots and chicken during the pureeing process to achieve the desired consistency, which was not indicated in the recipe. The facility also did not ensure that residents on a pureed diet received the recommended three ounces of protein during meal service. The scoop used to measure the pureed foods was a number 16 scoop, which only provided 2 3/4 ounces, falling short of the required three ounces. Interviews with staff revealed a lack of knowledge regarding the correct portion sizes and the appropriate scoop to use for measuring food. A staff member was unable to verbalize the amount of protein needed for residents on a pureed diet and was unaware of the measurement of the scoop used. The Dietary Manager confirmed that the incorrect scoop was used and acknowledged that the guide indicating the scoop sizes by color was no longer posted in the kitchen. The Dietary Manager also mentioned that staff sometimes add water or milk during the pureeing process to achieve the right consistency, which was not part of the recipe instructions.
Deficiencies in Food Labeling and Ice Machine Maintenance
Penalty
Summary
The facility failed to adhere to its policy regarding the labeling and dating of food items, as well as the timely disposal of expired foods. Observations revealed multiple instances of unlabeled and undated food items in the kitchen's reach-in coolers and on a steel table. These included a pan of tuna salad, a bag of cooked macaroni noodles, bottles of Zesty Italian dressing and strawberry syrup, a bag of brown sugar, and various salads and cheese products. Additionally, some items were found to be past their expiration dates, such as a bag of fried onions and a pan of macaroni salad. These deficiencies were confirmed by the Dietary Manager, who acknowledged the expectation that all foods should be labeled and dated, and leftovers discarded after three days. The facility also failed to maintain the cleanliness of the ice machine located in the staff break area. Observations noted white chalky streaks and a thick layer of chalky substance on the machine's exterior, as well as a thin layer of black substance on the inside panel. Interviews with the Administrator and Maintenance Director revealed that the ice machine should be cleaned daily by dietary staff and quarterly by maintenance, but the last quarterly cleaning was missed. The Dietary Manager, who was on vacation, confirmed that the machine was not cleaned as expected, and the Maintenance Director admitted that the last cleaning was incomplete.
Failure to Maintain Resident Dignity with Uncovered Catheter Bags
Penalty
Summary
The facility failed to uphold the dignity of two residents with indwelling urinary catheters, as observed by surveyors. Resident R11, who has a history of cerebral infarction, hemiplegia, hemiparesis, urinary retention, and is at risk for pressure ulcers, was found with an uncovered urinary catheter bag visible from the door on multiple occasions. Despite having a care plan in place to manage the urinary catheter and prevent infections, the catheter bag was not covered, which was confirmed as a dignity issue by a registered nurse. Similarly, Resident R20, diagnosed with chronic kidney disease and diabetes, was observed with an uncovered urinary catheter bag visible from the door. The resident's care plan included catheter care, yet the catheter bag remained uncovered during several observations. A registered nurse confirmed the lack of a dignity bag as a dignity issue. Both residents' catheter bags were not covered, contrary to the facility's policy on promoting and maintaining resident dignity.
Failure to Obtain Concurring Physician Signature on DNR Order
Penalty
Summary
The facility failed to obtain a concurring physician's signature on a Do Not Resuscitate (DNR) order for a resident, identified as R29, who was reviewed for DNR status. R29's medical record indicated diagnoses including Alzheimer's Disease, paranoid schizophrenia, and hyperlipidemia. The resident was originally admitted to the facility on May 4, 2022, and re-admitted on November 22, 2023. The medical record showed no Power of Attorney (POA) or Legal Guardian listed for R29. The Quarterly Minimum Data Set (MDS) assessments revealed severe cognitive impairment with Brief Interview Mental Status Scores (BIMS) of four and two, respectively. The DNR order for R29 was signed by an Authorized Person, purportedly a guardian, on May 4, 2022, and by one physician on May 7, 2022. However, there was no documentation confirming the existence of a guardian, POA, or healthcare agent for R29. An interview with a family member confirmed that no family member had legal guardianship or had been appointed as POA, although R29's preference was to remain a DNR. Interviews with the Unit Manager RN and LPN confirmed the absence of a healthcare agent and that R29's code status was changed to Full Code. The surveyor was unable to contact another family member to verify POA or guardianship status.
Facility Fails to Maintain Home-like Environment
Penalty
Summary
The facility failed to maintain a consistent home-like environment, as evidenced by several deficiencies observed in the living conditions of residents. Observations revealed missing floor tiles, peeling paint on walls, rust on resident equipment such as raised toilet seats, and persistent odors in resident areas. Specifically, rooms on the 300 hall were noted to have various issues, including dark brown substances on the frames of raised toilet seats, missing shower fixtures, stained tiles, and strong urine odors that permeated the resident rooms. Additionally, peeling paint and dark substances were observed on walls and ceilings in certain rooms. During an environmental tour, staff, including the RN Supervisor, Maintenance Director, and Housekeeper Supervisor, acknowledged the presence of these issues. The RN Supervisor noted that the urine odor was offensive to both residents and visitors, and the Maintenance Supervisor confirmed that the odor was embedded in the bathroom tiles, which required replacement. The Maintenance Director was unaware of the needed repairs and stated that maintenance repair forms were available at nurse stations. The staff also confirmed the presence of rust on the raised toilet seat frames and shower chairs, with the Maintenance Director indicating an attempt would be made to remove the rust.
Deficiency in Dialysis Care and Communication
Penalty
Summary
The facility failed to provide ongoing monitoring and care for a dialysis access site and did not ensure communication and collaboration with the dialysis center for a resident receiving dialysis services. The facility's policy on hemodialysis care, dated February 12, 2022, outlined the need for ongoing assessment and communication with the dialysis center, but these were not adhered to. The resident, who had diagnoses including type two diabetes mellitus with kidney complications, end-stage renal disease, and anemia in chronic kidney disease, had no physician orders for monitoring and care of the dialysis access site. The resident's medical records from September 5, 2023, to August 9, 2024, lacked consistent documentation of monitoring the dialysis access site and communication with the dialysis center. Interviews with nursing staff revealed that there were no specific orders for monitoring the dialysis access site, and it was the nurses' responsibility to ensure the site remained dry and intact. Observations confirmed the presence of a dialysis port with a dry dressing, but no written orders for its care. Additionally, the Dialysis Communication Sheets, which were supposed to be completed and exchanged between the facility and the dialysis center, were often missing or incomplete. Staff acknowledged the importance of these communication sheets but admitted to lapses in their completion and documentation, leading to a lack of proper communication and collaboration with the dialysis center.
Failure to Complete Discharge MDS Assessment
Penalty
Summary
The facility failed to complete and transmit a discharge Minimum Data Set (MDS) assessment within 14 days of discharge for a resident identified as R37. According to the facility's policy on Assessment Frequency/Timelines, an OBRA discharge assessment should be completed within 14 days of discharge. However, interviews with the Unit Manager and the MDS Coordinator revealed that no discharge assessment was completed for R37, and there was no documentation of the resident's stay in the facility's medical record system. R37 was admitted to the facility with diagnoses including lipoprotein deficiency, essential hypertension, low back pain, dementia, major depressive disorder, and altered mental status. The resident was admitted in February 2024 and discharged in March 2024 after being taken out of the facility against medical advice by the family. Despite the facility's policy requiring timely documentation of discharge needs and plans, there was no record of a discharge assessment or any documentation related to R37 in the facility's system.
Failure to Follow Hemodialysis Care Plan
Penalty
Summary
The facility failed to adhere to the care plan for a resident, identified as R31, who required hemodialysis due to end-stage renal disease. The care plan, dated June 12, 2024, specified interventions such as assessing the arteriovenous (AV) shunt for bruit and thrill every shift, maintaining communication with the dialysis center, and monitoring for signs of infection or renal insufficiency. However, a review of the administration record from August 1 to August 31, 2024, revealed no orders or documentation for ongoing monitoring and treatment of R31's dialysis access site. Additionally, progress notes from September 5, 2023, to August 9, 2024, lacked consistent documentation and proof of ongoing monitoring and communication with the dialysis center. Interviews with facility staff, including an LPN responsible for developing care plans and an RN who reviewed dialysis communication sheets, confirmed the absence of complete documentation and monitoring for R31's dialysis needs. The RN noted missing and incomplete dialysis communication sheets from September 11, 2023, to August 2, 2024. The LPN Unit Manager expressed that her expectation was for nurses to follow the care plans for residents, indicating a lapse in adherence to established protocols for R31's hemodialysis care.
Unsecured Oxygen Cylinder Poses Hazard
Penalty
Summary
The facility failed to ensure a safe environment by not securing an oxygen cylinder in a holder for a resident receiving oxygen therapy. During an observation, an unsecured oxygen cylinder was found on the floor of a resident's room, posing a potential accident hazard. The resident, who was diagnosed with acute hypoxemic respiratory failure, was receiving oxygen via a nasal cannula at the time. The facility's policy requires oxygen to be stored according to safety guidelines, which was not adhered to in this instance. Interviews with staff revealed a lack of awareness regarding the potential danger of an unsecured oxygen cylinder. A housekeeper, LPN, CNA, and RN all interacted with the resident's room but did not ensure the cylinder was secured. The LPN acknowledged the hazard and removed the cylinder upon discovery. The RN stated that her expectation was for CNAs to remove any unused oxygen cylinders from resident rooms and to ensure those in use were placed in holders, indicating a lapse in following these expectations.
Failure to Maintain Proper Catheter Care and Physician Orders
Penalty
Summary
The facility failed to have a physician's order for a resident with an indwelling catheter, identified as R20, who was one of eight residents with such catheters. R20 had a history of urinary tract infections and sepsis, and the medical record did not show an active order for the catheter. The catheter order was mistakenly discontinued shortly after being put in place. Observations revealed that R20's catheter tubing was improperly positioned, often coiled, touching the floor, or obstructed by being placed on the armrest of a chair, which could impede urinary flow. Multiple staff members, including registered nurses and licensed practical nurses, confirmed the absence of an active catheter order and acknowledged the improper positioning of the catheter tubing. Despite being informed and in-serviced about the correct positioning of catheter tubing, a certified nursing assistant was unaware that hanging the tubing on the armrest could obstruct urine flow. The facility staff, including the MDS Coordinator and unit manager, were observed repositioning the catheter tubing multiple times, indicating a repeated failure to maintain proper catheter care for R20.
Oxygen Therapy Administration and Signage Deficiency
Penalty
Summary
The facility failed to administer oxygen therapy in accordance with the physician's order for a resident, identified as R20, who was receiving oxygen therapy. The physician's order specified that oxygen should be administered via nasal cannula or simple mask at a rate of 2-4 liters per minute as needed for oxygen saturation below 90% or shortness of breath. However, observations revealed that R20 was receiving oxygen at a rate of 1.5 liters per minute, which was below the prescribed rate. This discrepancy was confirmed by a Licensed Practical Nurse (LPN) who was unaware of the correct oxygen setting until it was pointed out by the surveyor. Additionally, the facility did not place oxygen warning signage on the resident's door, as required by the facility's policy. This was observed on multiple occasions, and the absence of signage was confirmed by a Registered Nurse (RN) who was also unaware of this oversight until informed by the surveyor. The lack of signage posed a potential risk, as it is intended to prevent visitors from smoking in the room while oxygen is in use.
Failure to Use Alternative Interventions Before Administering Chemical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from chemical restraints, as evidenced by the administration of Haloperidol without attempting other interventions to manage the resident's behaviors. The resident, who had multiple diagnoses including mood disorder and anxiety disorder, was administered Haloperidol on several occasions for agitation and combative behavior. However, there was no documentation of alternative interventions being attempted prior to the administration of the medication. On one occasion, the resident was agitated and threw objects, leading to the administration of Haloperidol without any prior intervention attempts. Interviews with staff revealed that the resident was held down by staff members during the administration of Haloperidol, despite not acting out at the time. The resident expressed feeling overmedicated and reported being restrained by staff. Additionally, a Nurse Practitioner recommended an alternative medication, Ativan, for agitation, but there was no evidence that this recommendation was followed or that the order was initiated. The lack of documented interventions and the use of physical restraint during medication administration contributed to the deficiency identified in the report.
Failure to Report Alleged Restraint of Resident
Penalty
Summary
The facility failed to ensure that staff reported an allegation of restraining a resident during the administration of medication. The incident involved a resident with multiple diagnoses, including chronic obstructive pulmonary disease, hypertension, and anxiety disorder, who was reportedly agitated and received Haldol. According to a Certified Nurse Aide, the Director of Nursing (DON) and two Licensed Practical Nurses (LPNs) were involved in holding the resident down while the medication was administered, despite the resident not acting out at the time. This incident was not reported immediately to the Administrator or designee as required by the facility's policy. Further interviews revealed that another LPN observed the DON restraining the resident during a separate incident, where the resident was calm and wanted to discuss the confiscation of his vape pen. The LPN did not report the incident to the State Agency due to unfamiliarity with the reporting process. The Administrator was not initially aware of the restraint incident and later received a denial from the DON regarding the use of restraint. The failure to report these incidents promptly and appropriately constitutes a deficiency in the facility's adherence to its abuse and neglect policy.
Non-compliance with PRN Antipsychotic Medication Regulations
Penalty
Summary
The facility failed to ensure compliance with regulations regarding the use of PRN antipsychotic medications, specifically Haldol, for a resident. The resident was sent to the emergency room and returned with a PRN order for Haldol, which was entered into the electronic medical record as indefinite. This order was supposed to have an end date of 14 days later, but a new order was entered by an LPN extending the PRN Haldol without a face-to-face re-evaluation by a physician, as required. The resident received a dose of PRN Haldol beyond the 14-day period without the necessary physician evaluation and documentation. Additionally, a behavioral consultant recommended Ativan and Haldol for the resident's agitation, and while the physician and family were informed, there was no documentation from the physician indicating a continued need for the PRN medication. An interview with the physician confirmed that no progress note was made for the renewal of the PRN Haldol, highlighting a lapse in the documentation and evaluation process required for the continuation of PRN antipsychotic medications.
Failure to Provide Restorative Services
Penalty
Summary
The facility failed to provide restorative services for a resident who was discharged from skilled physical therapy with a recommendation for a Restorative Program. The resident, who had multiple diagnoses including chronic obstructive pulmonary disease, hypertension, and type 2 diabetes mellitus, was recommended to receive restorative services for ambulation, range of motion, transfer to a wheelchair, and bed mobility. However, there was no evidence in the medical records that these restorative recommendations were implemented prior to a specified date. Interviews with staff revealed communication breakdowns that contributed to the deficiency. The Physical Therapy Assistant (PTA) indicated that the resident was discharged from skilled therapy about two weeks prior, but the necessary form for restorative services was not provided. The Licensed Practical Nurse (LPN) stated that she did not receive communication from the therapy department regarding the resident's need for restorative services until a later date. The Director of Nursing (DON) acknowledged a lack of communication from the therapy department to the restorative nurse, which resulted in the resident not receiving the recommended services.
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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