Tucker Park Crossing Of Journey Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Tucker, Georgia.
- Location
- 4608 Lawrenceville Highway, Tucker, Georgia 30084
- CMS Provider Number
- 115561
- Inspections on file
- 30
- Latest survey
- January 30, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Tucker Park Crossing Of Journey Llc during CMS and state inspections, most recent first.
Surveyors found that the facility lacked a Legionella water management program, with leadership and maintenance staff unaware of any such program despite a prior isolated Legionella test. A nurse administering medication via a G-tube to a resident on Enhanced Barrier Precautions wore gloves but not a gown, contrary to facility policy, and reported not knowing a gown was required. An LPN performing wound care for a resident with a Stage IV sacral pressure ulcer and multiple comorbidities failed to disinfect the treatment cart, bedside table, or bed surface before placing clean supplies, used the same gloves to cleanse the wound and handle clean dressings, and only washed a reusable wound cleanser bottle with soap and water. Additionally, a resident’s oxygen concentrator was repeatedly observed with a filter covered in thick gray debris, while staff interviews showed confusion about who was responsible for cleaning oxygen equipment and how often tubing and filters should be maintained.
The facility failed to maintain clean PTAC filters in multiple resident rooms across all sampled halls. Surveyors observed that PTAC units in several rooms had two filters each that were covered with a grey, fuzzy substance thick enough to make the filters opaque, and re-observations on a later day showed the buildup remained. A walk-through with the Maintenance Director confirmed that PTAC units on all halls required cleaning, indicating that the issue was building-wide and affected the environment for residents, staff, and visitors.
A resident with dementia and moderate cognitive impairment, who required supervision for eating and mobility, was asked by an LPN to leave the dining room and return to her room after she had finished her meal so that other residents who had not yet eaten could do so without it appearing they had not been fed. When the resident returned to the dining room a short time later, the LPN again redirected her out, citing that others were still eating. Facility policies stated that residents have the right to exercise their rights without interference and to have unrestricted access to common areas unless there is a safety risk, and leadership later acknowledged that asking the resident to leave a preferred common area was a dignity and rights issue.
Surveyors found that the facility failed to control environmental hazards and prevent elopement. A cognitively intact resident with a seizure disorder and multiple cardiac and psychotropic meds kept and self-administered unsecured OTC cold and flu medication in his room without a physician order. Two other residents, one severely cognitively impaired with vascular dementia and visual loss and another with hemiplegia and contractures, had unsecured shaving razors accessible on top of bedside furniture, contrary to the DON’s expectation that razors be stored in enclosed bags out of reach. In addition, a resident with dementia, depression, and documented wandering and exit-seeking behaviors, care planned as at moderate to high elopement risk and ordered to have a wanderguard on a secure unit, was able to leave the building during a power disruption related to sprinkler system work; staff later observed her crossing multiple lanes of traffic after an exit door had been found open.
Surveyors identified multiple medication administration errors and policy noncompliance, including an LPN giving a multivitamin without minerals instead of an ordered vitamin-mineral tablet, failure to apply a prescribed Lidoderm patch when it was unavailable and inaccurate MAR documentation indicating it was given, administration of Metoprolol despite the resident’s SBP being below the ordered hold parameter, and an RN administering long-acting insulin outside the ordered morning time without priming the insulin pen or holding it in place after injection. Staff interviews revealed lack of adherence to MAR verification requirements and unfamiliarity with proper insulin pen technique.
Surveyors found that medications were not properly stored or managed, including expired floor-stock Dextrose injections discovered in a medication room and multiple insulin pens on a medication cart that were either expired, missing required open/expiration dates, or labeled with an incorrect 7-day expiration instead of the manufacturer-recommended 28 days. An RN acknowledged unawareness of expired Dextrose stored in a box under the counter, and an LPN confirmed that multiple nurses use the carts and that the insulin pens had not been labeled according to expectations. The DON reported that nurses are required to verify the MAR before administration, unit managers must routinely check carts and medication rooms, and all insulin on carts must be labeled with the date opened and a 28-day expiration, with undated or expired insulin to be discarded, noting that expired medications may be harmful and have unknown side effects.
A resident with moderate cognitive impairment and their POA were not invited to participate in care plan meetings, nor provided with copies or summaries of the care plan, despite facility policy requiring their involvement. The POA made multiple unreturned requests to participate, and staff interviews confirmed that only the resident was routinely invited unless family involvement was specifically requested.
A resident with moderate cognitive impairment and multiple diagnoses was transferred to the hospital after vomiting coffee ground-like emesis. Although staff attempted to contact the POA/family, no follow-up was made when there was no answer, resulting in the POA being unaware of the hospital transfer and ongoing hospitalization.
The facility did not honor a resident's right to voice grievances without discrimination or reprisal and failed to establish a grievance policy or make prompt efforts to resolve grievances.
A facility failed to maintain a resident's privacy by displaying a sign above their bed that disclosed personal information, indicating the resident was visually impaired. The resident, who had little cognitive impairment, was unaware of the sign. Staff interviews revealed a lack of awareness and adherence to privacy protocols, with a CNA relying on nurses for care instructions and an LPN stating she would have removed the sign if noticed. The Administrator was unaware of the sign and did not expect private information to be posted.
A facility failed to follow its bed-hold policy for a resident transferred to the hospital. Despite the policy requiring information to be provided during transfers, the resident did not receive the necessary paperwork on multiple occasions. Interviews revealed that staff were unaware of the proper procedures, and the RN responsible for the transfer had not been trained on the bed-hold process. The resident, with multiple health conditions, was transferred due to edema, but the facility's process breakdown led to the oversight.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in their care. One resident lacked a care plan for opioid management despite having multiple pain medication orders. Another resident, dependent on dialysis, did not have a care plan for her treatment. A third resident's care plan did not address his refusal to wear a splint, despite severe cognitive impairment. Staff interviews revealed a lack of coordination and oversight in updating care plans.
A resident with leg fractures was not administered medications according to physician's orders. The resident, aware of her pain levels, often requested specific pain medications, leading to frequent administration of hydrocodone-acetaminophen for pain levels outside the prescribed range. Interviews with staff confirmed that the MAR did not align with physician orders, indicating a failure in medication administration practices.
A resident with hemiplegia was not provided with a required right-hand grip splint for up to 4.5 hours as per their care plan. Observations showed the splint was not worn, and staff interviews revealed lapses in documentation and application. The facility's processes failed to ensure compliance with care plans and documentation requirements.
A resident with chronic respiratory conditions was not administered oxygen as ordered, with observations showing higher flow rates than prescribed. Interviews confirmed the discrepancy, highlighting a failure in following physician orders for oxygen administration.
The facility was found to have a staffing deficiency, with a one-star staffing rating and low weekend staffing for Q1 FY 2024. The DON revealed that the facility was operating with 60-70 percent of the required nursing staff and was extremely understaffed during this period. The Administrator was aware and discussed the issues during QAPI meetings.
The facility failed to provide a safe, clean, and comfortable homelike environment for 27 rooms on five halls, with issues such as dirty bathroom ceiling vent grills, oversized bathroom doors, damaged and missing drawer handles, dirty PTAC units, damaged wall handrails, brown ceiling tiles, and damaged walls. The Maintenance Director confirmed the unacceptable conditions and the absence of a specific Maintenance policy.
The facility failed to maintain a medication error rate below five percent, resulting in a 6.9% error rate. Two residents received crushed medications without physician orders, contrary to facility policy and best practices. Interviews confirmed the lack of necessary orders and highlighted the need for proper evaluation and adherence to medication administration guidelines.
The facility failed to follow standard infection control practices during catheter care for a resident with an indwelling catheter and a stage 4 pressure wound, and during meal tray distribution. CNAs did not perform hand hygiene between glove changes and between distributing meal trays, respectively.
The facility failed to conduct a Level II PASARR for a resident admitted with schizoaffective disorder. The Social Service Director confirmed that the diagnosis was not selected on the application, and the PASARR Level II evaluation was not completed, despite the facility's policy requiring it.
The facility failed to implement the care plan for a resident with multiple sclerosis, depression, and insomnia, who was at risk for falls. Despite the resident's repeated requests for side rails and the care plan's documented need for assist bars, the necessary evaluation and installation were not completed, leading to unmet needs.
The facility failed to provide adequate ADL care for three residents, specifically in nail care and scheduled showers. Two residents with severe cognitive impairment were found with extremely long fingernails, and another resident did not receive her scheduled bed baths for two weeks. The Director of Nursing confirmed these oversights.
The facility failed to provide appropriate treatment and services to prevent further decrease in range of motion for a resident with a contracture of her right hand. Despite the resident's medical history and care plan indicating the need for restorative therapy, staff interviews and observations revealed that the resident was not receiving the necessary care, and no splint or brace was in use.
The facility failed to provide adequate fall prevention interventions for a resident with multiple sclerosis and a history of falls, despite repeated requests for side rails. Additionally, an unsecured oxygen cylinder was found in another resident's room, violating safety protocols.
A resident with multiple diagnoses, including end stage renal disease and aphasia, did not have their G-tube placement properly checked before feeding. The RN failed to check the residual volume as required by the care plan and facility protocol, which was confirmed by the DON.
A resident with chronic obstructive pulmonary disease and acute respiratory failure was observed receiving oxygen without a physician order. The DON acknowledged the oversight, noting that the resident had been using oxygen since re-admission, but the order was not reactivated as required.
The facility failed to ensure full visual privacy for residents in three shared bedrooms due to missing or damaged privacy curtains. Observations revealed gaps and missing curtains, and staff interviews confirmed the lack of a maintenance work order system and the need for immediate repairs.
Infection Control Failures in Water Management, EBP, Wound Care, and Respiratory Equipment
Penalty
Summary
The deficiency involves multiple failures in the facility’s infection prevention and control program, including the absence of a Legionella water management program. Review of the Infection Prevention and Control Program policy revealed no language addressing Legionella testing or prevention. When surveyors requested the water management program, the Maintenance Director produced an empty clipboard and stated he had never heard of a water management program. The DON and the Administrator both reported they were unaware that there was no water infection prevention program in place, although the Administrator produced a single Legionella test report from the prior year. Surveyors also identified failures to follow Enhanced Barrier Precautions (EBP) and aseptic wound care technique. A nurse administering alprazolam via a G-tube to a resident on EBP wore gloves but did not don a gown for this high-contact care involving an indwelling medical device, despite facility policy requiring gown and gloves for such activities. The nurse later acknowledged she should have worn a gown and stated she was not aware that PPE, including a gown, was required when administering medications via the G-tube, even though EBP signage was posted on the resident’s door. In a separate observation, the LPN responsible for wound, skin, and ostomy care performed dressing care for a resident with a Stage IV sacral pressure wound without disinfecting the treatment cart, bedside table, or bed surface before placing clean supplies. The LPN used the same pair of gloves to cleanse the wound and then handle clean supplies and apply CollaSorb powder and calcium alginate dressing, and washed a reusable wound cleanser bottle with soap and water while gloved before returning it to the cart. The resident with the Stage IV sacral wound had significant comorbidities, including type 1 diabetes mellitus with neuropathy and circulatory complications, chronic kidney disease stage 3A, cerebrovascular disease, and polyneuropathy. The care plan for this resident included goals and interventions focused on wound healing, infection prevention, and monitoring for signs of infection, with physician orders specifying cleansing with wound cleanser or normal saline, application of collagen and calcium alginate, skin prep to the periwound, and dressing changes three times weekly and as needed. During interview, the LPN reported no observed breaches in infection control, believed her actions were appropriate, and stated that hand hygiene was only required twice during the procedure, and that washing the wound cleanser bottle with soap and water was sufficient, which contrasted with the DON’s stated expectations for disinfecting equipment and performing hand hygiene. Additional observations showed an oxygen concentrator in use by another resident with a filter covered in fuzzy, thick, dry gray particles on multiple days, while staff interviews revealed uncertainty among CNAs, nurses, the unit manager, and the DON about who was responsible for cleaning oxygen machine filters, how often tubing was changed, and how often filters should be cleaned, despite the DON stating that the RT was supposed to follow up on all residents on oxygen.
Failure to Maintain Clean PTAC Filters Throughout Facility
Penalty
Summary
The facility failed to maintain a safe, functional, and sanitary environment by not cleaning the Packaged Terminal Air Conditioner (PTAC) filters in multiple resident rooms across all sampled halls. On 01/27/2026, surveyors observed that PTAC units in rooms D16, D12, D15, E52, and E41 had two filters each, and the filters were covered with a grey, fuzzy substance approximately 1/8 inch thick in some cases, making the filters opaque. A re-observation of room D15 later that afternoon showed the filters still had the same grey, fuzzy buildup. On 01/28/2026, follow-up observations revealed that the PTAC filters in rooms D16, D12, D15, and E41 continued to have the grey, fuzzy substance that rendered the filters opaque. During a walk-through with the Maintenance Director on the same day, it was identified that all PTAC units in the building, including those on B, C, E, A, and D halls, required cleaning. This deficient practice was cited as a failure to provide a safe, easy-to-use, clean, and comfortable environment for residents, staff, and the public, with the report stating that it had the potential to cause respiratory irritation and exacerbation of conditions in residents with chronic obstructive pulmonary disease and other related lung diseases.
Resident Rights and Dignity Not Honored in Dining Room Access
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to make choices and have unrestricted access to common areas, as outlined in its own Resident Rights policies. The facility’s policies, revised in November 2025, state that residents have the right to be treated with respect and dignity, to exercise their rights without interference, and to have unrestricted access to common areas open to the public unless there is a safety risk. The resident involved, identified as R38, had diagnoses including unspecified dementia with moderate cognitive impairment (BIMS score of 8), anxiety, and repeated falls, and required supervision/touching assistance for eating and mobility. Her care plan identified a behavior problem related to going in and out of other residents’ rooms and removing items, with interventions focused on providing appropriate activities, anticipating needs, and monitoring behaviors and potential causes. On the observed date and time, during lunch in the E Hall dining room, an LPN entered the dining room and announced that residents who had already eaten should go to their rooms so that residents who had not yet eaten could do so and it would not appear that those without trays had not been fed. The LPN specifically told R38, who had already eaten, to leave the dining room so that other residents who had not been fed could eat, and R38 wheeled herself out of the dining room. When R38 returned a few minutes later, the LPN again redirected her out of the dining room, stating that the other residents had not yet finished eating. In an interview, the LPN acknowledged asking residents to leave so it did not look like a dignity issue to families and stated she did not feel it infringed on R38’s rights because the resident “didn’t know” due to dementia and memory issues. The DON later stated it was not acceptable to ask residents to leave a preferred space if that was where they wanted to be and that it was a dignity issue and a rights issue for the resident to be asked to go to her room.
Unsecured OTC Medications, Razors, and Failed Elopement Prevention
Penalty
Summary
The deficiency involves the facility’s failure to keep resident rooms free of accessible accident hazards, specifically unsecured over-the-counter (OTC) medications and shaving razors, and failure to adequately secure and monitor exit doors to prevent an elopement. Facility policy F 689 Accidents requires the environment to be as free from accident hazards as possible and calls for ongoing identification of safety risks, QAA/Safety Committee evaluation of hazards, and implementation and monitoring of interventions. The facility’s wandering/unsafe resident policy requires assessment of at-risk individuals, care plan identification of elopement risk, and inclusion of safety interventions. Despite these policies, surveyors observed multiple instances where hazardous items were accessible in resident rooms and where an at-risk resident was able to leave the building unsupervised. One cognitively intact resident with a seizure disorder, schizophrenia, depression, hypertension, and multiple prescribed medications, including anticoagulant and antiepileptic drugs, was found with two bottles of brand-name cold and flu OTC medication on a shelf at the foot of the bed. One bottle was nearly empty and the other half full, indicating prior use. The medications were unsecured and accessible. The resident reported he had purchased the cough medication himself because he felt the amount provided by the facility was not enough and that he took more of the medication because it worked for his cough. A nursing progress note documented that the resident had the cold medication in his room without a physician’s order and had been taking it at his discretion. The DON later stated that OTC medications should not be accessible to residents, except for an inhaler after assessment, due to concerns that residents, wandering residents, or visiting children might take them or that residents might not know how much to take. Two other residents were found with unsecured shaving razors accessible in their rooms. One resident with severe cognitive impairment, vascular dementia, visual loss in both eyes, difficulty walking, muscle weakness, and dependence on staff for wheelchair mobility had several shaving razors in a clear plastic bag on top of the bedside nightstand. The resident stated the razors belonged to him and that he used them, which is why they were present in the room. Another cognitively intact resident with hemiplegia/hemiparesis, contractures, difficulty walking, and need for assistance with personal care had a shaving razor in a cup on top of a dresser adjacent to the bed. This resident reported shaving independently and also shaving his head. The Unit Manager RN confirmed the presence of razors in both rooms and acknowledged they were a safety concern. The DON stated that residents are assessed on admission for ability to use razors and may keep them only if they are in an enclosed bag, out of reach, inside the nightstand, and care planned for their use, conditions that were not met in these observations. The facility also failed to prevent an elopement for a resident with dementia, depression, restless legs syndrome, and recent wandering and exit-seeking behaviors. A behavioral health evaluation documented wandering behaviors and difficulty redirecting the resident, and a care plan conference noted that the resident had been having exit-seeking behaviors requiring frequent redirection. The resident’s care plan identified a behavior problem related to walking the halls with belongings and refusing to return them to her room, and a subsequent care plan problem documented that she was at moderate to high risk for elopement, currently wandered, packed belongings to go home, and stayed near exit doors. Interventions included lodging on a secure unit and use of a wanderguard on the right wrist, with orders to check placement each shift and document its location. Despite being on a locked unit with exits that were supposed to be locked, staff interviews revealed that during an electrical outage associated with sprinkler system servicing, the resident was able to leave the building. An LPN reported that the resident went out the front exit during the outage. A CNA described walking by an exit door, feeling a breeze, and noticing the door was open. He checked a gate outside that door but could not open it and suspected the resident had used an alternate door near the activities area with a ramp. He then went to notify the RN and ran to the street, where he saw the resident crossing five lanes of traffic and continuing to walk several houses down from a visible house near the facility. The CNA stayed with the resident until assistance arrived. He stated that the resident exit sought daily, constantly went to the doors shaking them, and always had her bags packed and at the door. The DON and Administrator confirmed that sprinkler system testing had affected the power and that doors had been open while staff were conducting fire watch, during which time the resident was able to elope.
Medication Administration Errors and Policy Noncompliance
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate medication administration in accordance with physician orders and facility policy, resulting in a 16% medication error rate during the survey’s 25 observed opportunities. One resident had an order for a Multiple Vitamins-Minerals tablet once daily for supplementation, but the LPN administered a One-Daily Multivitamin without minerals, which did not match the ordered medication. Facility policies required verification of the right medication, dose, time, and route against the MAR and checking labels multiple times, but these steps were not followed in this instance. Another resident had an order for a Lidoderm (Lidocaine) 5% patch to be applied to the lower back every 12 hours and removed per schedule, but the nurse did not administer the patch because it was not available on the cart, in the medication room, or in the automated medication system. The physician was not notified of the missed dose, and the MAR reflected that the patch had been administered on multiple occasions despite the lack of available patches. The unit manager was initially unaware of the unavailability, and the resident later reported not receiving the patch the previous day or on the day of interview, instead requesting Tylenol for pain. A third resident had an order for Metoprolol Tartrate 25 mg by mouth once daily for HTN, with instructions to hold the dose if HR was 50 or lower or if SBP was below 120. At the time of administration, the resident’s BP was 109/54 mmHg and HR was 56, yet the LPN administered the medication outside the ordered BP parameter, stating she only considered the HR and not the BP. A fourth resident had an order for Insulin Glargine (Lantus) 26 units subcutaneously every morning and at bedtime for diabetes, but the RN administered the morning dose at 1:11 PM instead of in the morning, did not prime the insulin pen, and did not hold the pen in place after injection as required by manufacturer guidance and facility expectations. The RN reported being unfamiliar with the procedures for priming and holding the insulin pen and had not received training on the facility’s insulin pen administration policy.
Expired and Improperly Labeled Medications and Insulin Pens
Penalty
Summary
Surveyors identified a failure to properly store and manage medications, including expired and undated drugs, in a medication room and on a medication cart. Review of the facility’s policy "Storage of Medications F761" stated that discontinued, outdated, or deteriorated drugs or biologicals must not be used and must be returned to the pharmacy or destroyed. During an observation of the A/B/E-Hall medication room on the second floor with a unit manager RN, five floor-stock 50% Dextrose injection 25 g/50 mL units were found in a box under the counter with an expiration date of 07/2025. The RN confirmed the medications were expired and stated she was not aware they were in that box. During a separate observation of the B-Hall medication cart with an LPN, surveyors found multiple issues with insulin pens. One insulin Aspart pen had an open date of 1/1/2026 and an expiration date of 1/31/2026, indicating it had been in use for more than 28 days and was expired as of 1/28/2026. One Lantus Solostar insulin pen was open and in current use with no documented open date or expiration date. One insulin Lispro (Humalog) KwikPen was labeled with an open date of 1/28/2026 and an expiration date of 2/5/2026, reflecting a 7-day expiration instead of the manufacturer-recommended 28 days after opening. The LPN confirmed the labeling issues, stated that multiple nurses use the carts and that she did not open or label those pens, and acknowledged that insulin removed from refrigeration should be dated and assigned a 28-day expiration. The DON later stated that nurses are required to verify the MAR three times before administration, unit managers are responsible for weekly cart checks and daily medication room checks, and that all insulin on carts must be labeled with the date opened and a 28-day expiration, with undated or expired insulin to be discarded, and that use of expired medications may be harmful with unknown potential side effects.
Failure to Involve Resident and POA in Care Planning
Penalty
Summary
The facility failed to ensure that a resident and the resident's Power of Attorney (POA) were invited to participate in the development and implementation of the resident's person-centered care plan. Review of facility policies indicated that both the resident and their representative should be provided with a summary of the baseline care plan within 48 hours and be involved in the comprehensive care planning process. However, documentation in the electronic medical record did not show that the resident or POA were invited to or attended care plan meetings, nor was there evidence that they received copies of the care plan or signed acknowledgments. Interviews revealed that the POA had expressed concerns about the resident's care and had made multiple attempts to contact the facility to participate in care planning, but these calls were not returned. The Clinical Reimbursement Coordinator stated that only the resident was invited to care plan meetings unless the resident specifically requested family involvement, despite the resident having moderate cognitive impairment as indicated by a BIMS score of 11. The administrator later confirmed that both the resident and their representative should have been invited, but this was not done in this case.
Failure to Notify POA/Family of Resident's Change in Condition and Hospital Transfer
Penalty
Summary
The facility failed to notify the Power of Attorney (POA) or family of a change in condition for one resident. The resident, who had diagnoses including asthma and end-stage renal disease and was assessed as having moderate cognitive impairment, experienced an episode of vomiting coffee ground-like emesis. The in-house nurse practitioner was notified and recommended hospital transfer, after which Emergency Medical Services (EMS) transported the resident to the hospital. Although an attempt was made to contact the family, there was no answer, and no follow-up call was documented or made by subsequent shifts. The POA later reported being unaware of the resident's hospital transfer and continued hospitalization.
Failure to Honor Resident Grievance Rights
Penalty
Summary
The facility failed to honor the resident's right to voice grievances without discrimination or reprisal. Additionally, the facility did not establish a grievance policy or make prompt efforts to resolve grievances as required. This deficiency was identified based on observations and findings that the facility did not have appropriate procedures in place to address and resolve resident grievances in a timely and non-discriminatory manner.
Privacy Breach Due to Improper Display of Resident Information
Penalty
Summary
The facility failed to maintain the privacy of a resident by displaying a sign on the bedroom wall that disclosed protected personal information. The sign, which stated 'visually impaired,' was observed above the bed of a resident who had highly impaired vision but little to no cognitive impairment, as indicated by a Brief Interview of Mental Status (BIMS) score of 15. The resident was unaware of the sign's presence when asked about it. Interviews with staff revealed a lack of awareness and adherence to privacy protocols. A Certified Nursing Assistant (CNA) mentioned that nurses typically informed them of residents' diagnoses and care instructions, and that they could access the resident's Plan of Care (POC) on the computer if needed. A Licensed Practical Nurse (LPN) stated that she had received training on dignity and privacy and would have removed the sign if she had seen it, explaining the reason to the resident if they were alert. The facility's Administrator was unaware of the sign and stated that it was not their expectation for private information to be posted on residents' walls.
Failure to Follow Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to ensure a bed-hold policy was followed for a resident who was transferred to the hospital. The facility's policy, revised in May 2023, requires that information about the bed-hold policy be provided upon admission and during transfers for non-emergency hospitalizations or therapeutic leave. However, during an emergency transfer on 10/27/2024, the resident did not receive the necessary bed-hold paperwork. Interviews revealed that the Licensed Practical Nurse (LPN) and the Business Office Manager (BOM) were not aware of the proper procedures, and the Registered Nurse (RN) responsible for the transfer was not trained on the bed-hold process. The resident involved had multiple diagnoses, including chronic kidney disease, heart failure, and diabetes, and was transferred to the hospital due to edema. Despite having a cognitive status indicating little to no impairment, the resident did not receive the bed-hold paperwork during transfers on three separate occasions. The BOM confirmed that the bed-hold policy was not issued due to a break in the facility's process, and the Director of Nursing (DON) acknowledged the responsibility of the nursing staff to communicate necessary information to the BOM. The RN involved admitted to not knowing about the bed-hold requirement and had not received training on the procedure.
Deficiencies in Care Plan Development and Implementation
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents, leading to deficiencies in their care. For one resident, identified as R23, the facility did not create a care plan specific to the management of opioid medications despite the resident having multiple physician orders for pain management, including tramadol, hydrocodone-acetaminophen, and a fentanyl patch. Interviews with staff revealed that care plans were supposed to be updated quarterly and involve the interdisciplinary team, but there was a lack of coordination and communication, resulting in the omission of a critical aspect of the resident's care plan. Another resident, R64, who was dependent on renal dialysis, did not have a care plan addressing her dialysis treatment. Despite having a port in her chest and attending dialysis sessions three times a week, this essential aspect of her care was overlooked. Interviews with the MDS coordinators and the Director of Nursing confirmed that the responsibility for updating care plans was shared among the MDS team and nursing staff, but an oversight led to the absence of a dialysis care plan for this resident. The third deficiency involved resident R19, who had severe cognitive impairment and required restorative care, including the use of a splint. The care plan did not address the resident's refusal to wear the splint, which was documented in the occupational therapy discharge summary. Staff interviews indicated that the MDS team and nursing staff were responsible for updating care plans, but there was a failure to document and address the resident's refusal, leading to an incomplete care plan for this resident.
Failure to Administer Medications According to Physician's Orders
Penalty
Summary
The facility failed to administer medications according to the physician's orders for a resident with a history of leg fractures. The resident, who has little to no cognitive impairment, was prescribed tramadol for severe pain, hydrocodone-acetaminophen for moderate pain, and a fentanyl patch. However, the Medication Administration Record (MAR) showed that hydrocodone-acetaminophen was frequently administered for pain levels that were higher than the prescribed range for this medication, indicating a deviation from the physician's orders. Interviews with the resident and staff revealed that the resident often requested specific pain medications based on her self-reported pain levels, which were not always aligned with the prescribed pain scale. The Licensed Practical Nurse (LPN) acknowledged that the resident was aware of her pain levels and medication preferences, and the Director of Nursing (DON) confirmed that staff should follow physician orders and contact the physician for any necessary adjustments. Despite this, the MAR did not align with the physician's orders, indicating a failure in medication administration practices.
Failure to Provide Required Splint for Resident
Penalty
Summary
The facility failed to provide a right-hand grip splint for a resident, identified as R19, for up to 4.5 hours as required. R19 was admitted with diagnoses including hemiplegia and hemiparesis following cerebrovascular disease affecting the right dominant side. The resident's care plan included wearing a grip splint on the right hand to maintain function, as recommended by occupational therapy. However, observations revealed that R19 was not wearing the splint during multiple checks, and it was found in the resident's drawer instead. Interviews with staff indicated a lack of documentation and follow-through on the resident's care plan. The MDS coordinators acknowledged that the order for the splint might have been overlooked, leading to a lapse in documentation and application. The LPN and CNA involved confirmed that the splint was not consistently applied, and there was no documentation to support its use in the current year. The facility's policy required that splints be applied and documented, but this was not adhered to in R19's case. The Director of Nursing expressed expectations that the restorative team and nursing staff should ensure residents receive care as ordered, including the application of splints. However, the lack of communication and coordination between therapy, nursing, and restorative teams resulted in the resident not receiving the necessary rehabilitative care. This deficiency highlights a failure in the facility's processes to ensure compliance with care plans and documentation requirements.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to administer oxygen as ordered for a resident, identified as R9, who was reviewed for respiratory care. R9's medical records indicated diagnoses including chronic systolic congestive heart failure, pleural effusion, chronic obstructive pulmonary disease, and acute and chronic respiratory failure. The resident's physician orders dated October 1, 2024, specified oxygen administration at 2 liters per minute (LPM) via nasal cannula. However, observations on October 27 and 28, 2024, revealed that the oxygen flow rate was set at 3 LPM and 3.5 LPM, respectively, which was not in accordance with the physician's orders. Interviews conducted with the Licensed Practical Nurse (LPN) and the Director of Nursing (DON) confirmed the discrepancy in oxygen administration. The LPN acknowledged that the oxygen was set at 3.5 LPM, contrary to the prescribed 2 LPM. The DON expressed that staff are expected to follow physician orders and noted that setting oxygen at a higher level could have adverse effects depending on the resident's medical condition. This failure to adhere to the prescribed oxygen administration protocol constitutes a deficiency in the facility's respiratory care practices.
Staffing Deficiency and Low Weekend Staffing
Penalty
Summary
The facility was found to have a deficiency in staffing levels, as evidenced by a one-star staffing rating and low weekend staffing for the first quarter of Fiscal Year 2024. The facility census was 115 residents. The Director of Nursing (DON) revealed that during the period from October 1, 2023, to December 31, 2023, the facility was not utilizing agency staff, had only one unit manager, and was operating with 60-70 percent of the required nursing staff. This resulted in the facility being extremely understaffed during this period. The Administrator was aware of the staffing issues and discussed them during Quality Assurance and Performance Improvement (QAPI) meetings.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable homelike environment for 27 rooms on five halls. Observations revealed multiple deficiencies including dirty bathroom ceiling vent grills, oversized bathroom doors that could not be closed, damaged and missing drawer handles and doors on bedside nightstands and clothing chests, dirty and damaged PTAC units, damaged wall handrails, brown ceiling tiles, damaged bathtubs, and damaged, unpainted walls. Specific rooms such as D-5, D-7, D-8, C-22, B-24, B-30, A-19, A-20, E-51, E-52, E-50, E-45, D-1, and several others were noted to have these issues during initial and follow-up observations by surveyors on different dates. In Room B-24, paint was missing around the toilet paper holder, and in Room B-30, there were three holes in the sheetrock behind the bed. Room A-19 had unlabeled and unbagged bath basins and a urinal, spider webs with leaves on the window, dark scuff marks on the wall, a baseboard coming off the wall, and a dirty personal refrigerator. Similar issues were found in Rooms A-20, E-51, E-52, E-50, E-45, D-1, and other rooms, including missing paint, holes in walls, dirty and unlabeled basins, and spider webs with leaves on windows. The Maintenance Director confirmed the unacceptable conditions and stated that he managed and tracked all facility maintenance work orders through the TELS computer system. However, he was not aware of any specific Maintenance policy in place. The Administrator confirmed the absence of an Environmental Maintenance policy. An LPN revealed that maintenance work orders were reported through a computer maintenance system, which was considered more manageable than the previous system of writing work orders in a service requests binder at the nursing stations.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure the medication error rate was less than five percent, resulting in a medication error rate of 6.9%. Specifically, the facility did not obtain physician orders to crush medications prior to administration for two residents. For Resident 37, who had severe cognitive impairment and multiple diagnoses including acute kidney failure and dysphagia, nine medications were crushed and administered without a physician's order. Similarly, for Resident 90, who had moderate cognitive impairment and multiple diagnoses including type 2 diabetes mellitus and Alzheimer's disease, six medications were crushed and administered without a physician's order. During interviews, it was confirmed by an LPN and the Director of Nursing (DON) that there were no orders to crush the medications for these residents. The DON also confirmed that residents must be evaluated by speech therapy if they have difficulty swallowing medications and that certain medications, such as enteric-coated medications and methadone, should not be crushed without a physician's order. The facility's policy on administering medications requires that medications be administered in accordance with physician orders, including any required time frames.
Infection Control Deficiencies in Catheter Care and Meal Tray Distribution
Penalty
Summary
The facility failed to follow standard infection control practices during catheter care for one resident and during meal tray distribution. Specifically, a Certified Nursing Assistant (CNA) did not perform hand hygiene between glove changes while providing catheter care to a resident with an indwelling catheter and a stage 4 pressure wound. The CNA acknowledged the lapse in hand hygiene during an interview. Additionally, another CNA was observed distributing meal trays to residents without sanitizing hands between each tray. This CNA was unaware that hand hygiene was required between each resident tray served. The resident involved in the catheter care deficiency had a medical history that included type 2 diabetes, transient cerebral ischemic attack, vascular dementia, and hemiplegia affecting the left nondominant side. The resident's care plan indicated the presence of an indwelling catheter related to a stage 4 pressure wound on the sacrum. The Director of Nursing confirmed that hand hygiene should be conducted before resident contact, when transitioning from clean to unclean tasks, and before and after applying gloves.
Failure to Conduct Level II PASARR for Resident with Schizoaffective Disorder
Penalty
Summary
The facility failed to ensure a Level II PASARR was conducted for a resident (R40) who was admitted with a diagnosis of schizoaffective disorder. The facility's policy requires that the recommendations of the PASARR Level II and the PASARR evaluation report be incorporated into the resident's assessment, care planning, and transition of care. However, a review of R40's Annual Minimum Data Set (MDS) revealed that the PASARR Level II evaluation was not completed, and the diagnosis of schizoaffective disorder was not selected on the application. The Social Service Director (SSD) confirmed that the Level I PASARR was to be completed by the hospital prior to admission and that Level I and Level II PASARRs for all residents are completed on admission. Despite this, the SSD admitted that she had not personally completed a PASARR for R40 and that the business office manager was responsible for the referral and documentation in the electronic medical record. During an interview, the SSD stated that if residents had documented mental health issues, she would inform the MDS nurse to include the diagnosis. However, in this case, the diagnosis of schizoaffective disorder and depression was not selected on the application, leading to the failure to conduct a Level II PASARR for R40. This oversight indicates a lapse in the facility's adherence to its own PASARR policy and the federal and state regulations mandating the incorporation of PASARR recommendations into resident assessments and care planning.
Failure to Implement Care Plan for Resident at Risk for Falls
Penalty
Summary
The facility failed to implement the care plan for a resident diagnosed with multiple sclerosis, depression, and insomnia, who was at risk for falls and had gait/balance problems. The care plan included an intervention for the resident to be evaluated for assist bars to aid in positioning in bed. However, despite the resident's repeated requests for side rails to prevent falls and discussions with the Social Worker and nurses, the side rails had not been installed. The Quarterly Minimum Data Set (MDS) indicated the resident had moderate cognitive impairment with a BIMS score of 12. Interviews with the MDS Coordinator and the Director of Nursing (DON) confirmed that the care plan documented the need for assist bars and that the rehabilitation staff must evaluate the resident and obtain consent before installation. The MDS Coordinator and DON also verified that the clinical team and unit nurses are responsible for updating and following the care plans. Despite these protocols, the necessary evaluation and installation of assist bars for the resident had not been completed, leading to a failure in meeting the resident's needs as outlined in the care plan.
Failure to Provide Adequate ADL Care
Penalty
Summary
The facility failed to provide adequate ADL care for three residents, specifically in the areas of nail care and scheduled showers. Resident R23, who has severe cognitive impairment and is dependent on staff for personal hygiene, was observed with extremely long fingernails. Despite having a care plan that includes regular nail care and assistance with ADLs, R23 reported that no one had offered to cut or trim his fingernails. Similarly, Resident R87, who also has severe cognitive impairment and requires assistance with personal hygiene, was found with extremely long fingernails. The care plan for R87 includes regular nail care on bath days, but this was not carried out as required. The Director of Nursing confirmed that fingernail care should be part of ADL care and acknowledged the oversight for both residents. Resident R70, who has little cognitive impairment but requires substantial assistance with personal hygiene, did not receive her scheduled bed baths. Her care plan specifies that she should receive bed baths three times a week, but records show she only received a few bed baths in April and none in the first week of May. R70 reported that it had been two weeks since her last bath and that staff informed her she would not receive one until the following Monday, without providing a reason. This failure to adhere to the care plan was also confirmed by the Director of Nursing.
Failure to Provide Restorative Care for Resident with Contracture
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent further decrease in range of motion for a resident (R22) receiving restorative care. The resident, who has a medical history including dementia, altered mental status, adult failure to thrive, and adjustment disorder with depressed mood, was observed to have a contracture of her right hand. Despite this, no splint or brace was noted during the observation, and the resident was not listed for restorative care. Interviews with staff, including a Restorative CNA, LPNs, and a Certified Occupational Therapy Aide, revealed that the resident had not been on the therapy caseload since 2022 and was not receiving the necessary restorative therapy services to address her condition. The facility's policies on range of motion exercises and restorative services indicate that residents with limited range of motion should receive appropriate treatment to prevent further decline. However, the staff interviews and observations showed a lack of adherence to these policies. The Restorative CNA confirmed that the resident was not on the list for restorative care, and the LPNs were unaware of any ongoing therapy for the resident. The Certified Occupational Therapy Aide also confirmed that the resident had not been on the therapy caseload since 2022, highlighting a significant gap in the resident's care plan and the facility's failure to provide necessary restorative services.
Failure to Prevent Falls and Secure Oxygen Cylinder
Penalty
Summary
The facility failed to provide interventions to prevent falls for a resident with multiple sclerosis, depression, and insomnia, who had a history of falls. Despite the resident's repeated requests for side rails and multiple documented falls, the facility did not evaluate or provide side rails. Staff interviews revealed that the resident's safety awareness was poor, and various fall prevention measures were discussed but not fully implemented, such as the absence of fall mats and assist bars. The resident continued to experience falls while reaching for items, indicating inadequate fall prevention interventions by the facility. Additionally, the facility failed to ensure an oxygen cylinder was stored and secured for a resident receiving oxygen therapy. An unsecured oxygen cylinder was observed on the floor of the resident's room, which was confirmed by the Director of Nurses. The facility's policy required portable oxygen cylinders to be strapped to the stand, but this was not followed, posing a safety hazard. The resident had diagnoses including vascular dementia and generalized anxiety disorder, and the unsecured oxygen cylinder was a direct violation of the facility's safety protocols.
Failure to Properly Check G-Tube Placement
Penalty
Summary
The facility failed to properly check for Gastric tube (G-tube) placement for a resident receiving nutrition through a G-tube. The resident, who was admitted with diagnoses including end stage renal disease, adult failure to thrive, and aphasia following cerebrovascular disease, had a care plan that required checking for tube placement and gastric contents/residual volume per facility protocol. However, during an observation, a registered nurse initiated the tube feeding without checking the residual volume, which was a required step according to the resident's orders and facility protocol. The Director of Nursing confirmed that the proper procedure for checking G-tube placement included verifying orders, ensuring the feeding bottle had not expired, listening to bowel sounds, injecting air, listening for placement, and checking residual. Despite this, the registered nurse only injected air and listened for placement, neglecting to check the residual volume. This oversight was verified through staff interviews and record reviews, indicating a failure to adhere to the established protocol for G-tube feeding initiation.
Failure to Obtain Physician Order for Oxygen Therapy
Penalty
Summary
The facility failed to obtain a physician order for oxygen therapy for a resident diagnosed with chronic obstructive pulmonary disease and acute respiratory failure. The resident, who had no cognitive impairment, was observed receiving oxygen via nasal cannula at four liters per minute on multiple occasions. However, a review of the resident's clinical record revealed no physician order for this oxygen administration. The Director of Nursing acknowledged that the oxygen order was only entered into the system after the surveyor's observation, despite the resident having used oxygen since their re-admission to the facility. The DON explained that oxygen orders are typically reactivated upon a resident's return to the facility after discharge, but this process was not followed in this case. The unit manager is responsible for auditing oxygen orders, but this oversight was not caught until the surveyor's investigation.
Failure to Ensure Full Visual Privacy in Shared Resident Bedrooms
Penalty
Summary
The facility failed to ensure that privacy curtains provided full visual privacy for three shared resident bedrooms. Observations revealed that room E44 had a privacy curtain missing several hooks, causing a large gap and not providing full privacy for the resident in the B bed. Room D5's privacy curtain also had missing hooks and could not be drawn for full privacy while providing care for the resident. Additionally, room B39-1 had hooks on the curtain track but no privacy curtain was observed to provide privacy for the resident during care. Interviews with staff confirmed the lack of a maintenance work order system at nursing stations and acknowledged the unacceptable conditions of the rooms needing immediate attention and repairs.
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Surveyors found that clean linens and personal clothing were stored and staged in close proximity to the dirty laundry area, with an open door between the clean and soiled sides and all washer and dryer doors open. Clean resident clothes, unlabeled garments, and bagged items were placed next to dryers and directly in front of the dirty linen room, and dirty barrels had to be pushed past racks of clean clothing to reach the washers, contrary to facility policies requiring separation of clean and soiled linens. Environmental staff believed keeping doors open and covering dirty barrels reduced infection spread, while the Environmental Services Director, IP nurse, and Administrator acknowledged that the dirty room door should be closed, linens should not be on dirty barrels, and clean resident clothing should not be stored in that location.
A resident with a suprapubic catheter, colostomy, sacral wound, and dependence on staff for bathing and hygiene was care planned for Enhanced Barrier Precautions (EBP), including use of PPE during high-contact care. During observed catheter care and a bed bath, a CNA wore only gloves and did not don a gown, despite EBP signage and a star posted on the door and PPE supplies available outside the room. In interviews, the CNA admitted forgetting to wear a gown and not recognizing additional required actions, while the IP nurse and DON confirmed that staff had been educated that gowns and gloves are required for high-contact care involving indwelling devices and wounds under the facility’s EBP policy.
A resident with multiple neurologic and psychiatric diagnoses, intact cognition, and unilateral functional limitations was found with an open box of lubricant eye drops stored at the bedside without any documented assessment for self-administration or prescriber’s order for self-administration or bedside storage, contrary to facility policy. Observations on multiple days confirmed the eye drops remained at the bedside, while staff interviews showed that CNAs and the IP recognized that residents were generally not to self-administer medications and that bedside medications required assessment and orders. The Administrator confirmed that the resident should not have had eye drops in the room and that residents with bedside medications are typically assessed for self-administration, and staff acknowledged that unsecured eye drops at the bedside could be accessed or ingested by other residents and cause harm.
The facility failed to maintain a safe, clean environment when multiple ceiling tiles throughout the building, including above a resident’s bed, near the nurses’ station, in a glass day room above a resident’s chair, and in a main hall, were observed with brown circular stains, bulging, and a white moldy substance. The Maintenance Director confirmed the stained and bulging tiles, acknowledged the risk that tiles above a resident’s bed could fall, and attributed the condition to rain-related roof leaks. The Administrator also confirmed that roof leaks and recent rainfall caused the brownish stains despite her reported daily rounds.
A resident with severe cognitive impairment, on hospice and fully dependent for ADLs, was sexually abused when another cognitively impaired male resident with a long-standing history of sexually inappropriate behavior toward female residents entered her room and placed his hand inside her pants. The abusing resident had multiple dementia and psychiatric diagnoses, was care planned for sexually inappropriate behaviors with prior documented incidents, and was on psychotropic medication for OCD-related sexual obsession. Despite these known risks and existing care plan interventions, he was able to access the female resident’s room and make inappropriate physical contact, and the facility’s investigation substantiated the abuse.
Surveyors found that the facility failed to develop and implement complete, person-centered care plans for two residents. One resident was receiving an antipsychotic (Haloperidol) for schizophrenia with associated behavior and side-effect monitoring orders, but there was no corresponding care plan addressing antipsychotic use or its indication. Another resident had an indwelling Foley catheter for neurogenic bladder related to prostate cancer, with goals to prevent catheter-related trauma; however, the care plan omitted key interventions such as balloon volume parameters and use of a leg strap or securement device, despite physician orders requiring a leg strap and observations showing the catheter positioned under the leg without securement. An MDS coordinator and the administrator acknowledged that required interventions and standard catheter care components were missing from the care plans.
A resident with a history of resistiveness to care and noncompliance with the non‑smoking policy had a comprehensive care plan that was not updated to reflect multiple interventions implemented in response to repeated smoking and vaping violations. Although the care plan noted the need for supervision while smoking and review of the smoking policy, it did not include measures such as daily room searches for smoking materials, added smoke detection in the room, relocation closer to the nurses’ station, q2h visual rounds for smoke, post‑outing nursing checks, initiation of a PAR process for vaping, or issuance of a discharge notice. Facility forms showed inconsistent documentation of daily room searches and incomplete IDT documentation on the PAR tracking, despite multiple documented episodes of policy violations and removal of vaping devices.
A cognitively intact but physically impaired resident with a history of noncompliance with the facility’s non‑smoking policy repeatedly smoked and vaped in his room while keeping multiple vape devices and other items at bedside. The facility’s Smoking Policy required that non‑compliant smokers have daily documented searches and be prohibited from keeping smoking materials in their rooms, yet monitoring forms showed many days without documented searches, Patient at Risk tracking was incomplete, and staff acknowledged that daily room checks and frequent rounds were not consistently performed. Multiple staff, including a CNA, social worker, Infection Preventionist, MDS coordinator, Activities Director, and the Administrator, reported ongoing violations and repeated discovery of vape devices in the resident’s room, including during surveyor observations, demonstrating that the environment was not maintained free from accident hazards and that required supervision and monitoring were not reliably implemented.
Surveyors found that a treatment cart containing topical medications was left unlocked and unattended in a hall across from a resident’s room after wound care was completed by an LPN. The facility’s policy requires that medication carts and supplies be locked or attended and accessible only to licensed or otherwise authorized staff. During interviews, the LPN confirmed the cart had been left unlocked and unattended, the IP LPN confirmed the LPN’s report that the cart was left unlocked, and the Administrator stated that all medications, including topical medications, were expected to be locked when not in sight of authorized staff.
The facility failed to implement its infection prevention and control program by not operationalizing a documented Legionella water management plan despite having a written policy, and by not fully implementing Enhanced Barrier Precautions (EBP) for residents with indwelling devices and other risks. A resident with an indwelling urinary catheter had no EBP care plan or orders, no EBP signage, and staff providing catheter care wore only gloves without gowns, while multiple staff members reported not knowing what EBP was or misidentified who should be on EBP. Another resident receiving tube feeding had care initiated by an LPN who wore gloves but no gown and repeatedly touched her hair with the same gloved hands before handling the feeding tube and equipment, later acknowledging she should have changed gloves and was unaware of EBP requirements, even though other clinical staff stated gowns and gloves should be used for feeding tube care. A resident on isolation for C. diff had a door sign indicating isolation but no instructions for visitors on required PPE or to seek staff guidance, and the IP confirmed there was no system to direct visitors about precautions, contributing to the overall infection control deficiency.
Failure to Maintain Separation of Clean and Soiled Laundry
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to separation of clean and soiled linens. Facility policies titled “Infection Prevention and Control Program” and “Handling Soiled Linens” required that clean linen always be separated from soiled linen. During an observation of the laundry area, all washer and dryer doors were open in the clean linen area. Clean linens, including sheets, towels, blankets, and washcloths, were folded on a table to the left of the washer and dryer room. On the right side of the room, next to the dryers and directly in front of the open door to the dirty laundry room, there were residents’ clean clothes on a rack, piles of folded clean clothes to be hung, a rack of unlabeled clothes, and a bag of unlabeled clothes. Dirty laundry barrels had to be pushed past the clean clothing on the racks to reach the washers, placing soiled items in close proximity to clean items despite policy requirements for separation. Environmental staff working in the laundry stated they believed they were reducing the spread of infection by keeping all doors open, covering dirty barrels, and circulating air, and they explained that the uncovered rack and bagged clothes near the dirty area were no-name clothes sometimes distributed to residents in need. They also stated that the rack of clean personal resident clothing parked in front of the open dirty linen room door was awaiting distribution by a staff member who worked only at night. The Environmental Services Director reported that the door to the dirty side of the laundry should always be closed and that no linen should be on top of dirty barrels. The Infection Preventionist nurse, when shown pictures and concerns about cross-contamination, confirmed there was a problem in the laundry but stated she had not been aware of it previously. The Administrator stated that residents’ clothes should not be stored where they were observed and should be handed out immediately once clean, and that she expected the laundry to be organized to prevent cross-contamination between dirty and clean clothes.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff followed its Enhanced Barrier Precautions (EBP) policy for the use of personal protective equipment (PPE) during high-contact care. The facility’s EBP policy, updated February 2025, requires gowns and gloves for residents with wounds and/or indwelling medical devices, including urinary catheters and ostomies, when staff perform high-contact activities such as bathing, dressing, toileting, hygiene, and catheter care. The policy also directs that gowns and gloves be made available near or outside the resident’s room and that EBP be implemented for residents with indwelling devices or wounds, even if they are not known to be infected or colonized with a multidrug-resistant organism. The resident involved had a suprapubic catheter, colostomy, sacral wound, and neurogenic bladder and bowel, and was care planned for EBP implementation during catheter and skin care. The resident was cognitively intact but dependent on staff for bathing, dressing, toileting, hygiene, bed mobility, and transfers, and used an indwelling catheter and ostomy. During an observation, a CNA provided suprapubic catheter care and a bed bath to this resident while only wearing gloves, despite EBP signage and a star posted on the door and PPE supplies available outside the room. The CNA did not don a gown and was unable to identify any additional actions needed before care until prompted about the EBP signage, at which point he acknowledged he should have worn a gown but forgot. In a subsequent interview, the IP nurse and DON confirmed that staff had been educated that gowns are required during high-contact care for residents with catheters, colostomies, and other devices, and that the posted signage and star were intended to alert staff to the need for enhanced PPE use.
Failure to Assess and Obtain Orders for Self-Administration and Bedside Medication Storage
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policies for self-administration of medications and bedside medication storage for one resident. The facility’s policies require that residents who wish to self-administer medications must be assessed by the interdisciplinary team for cognitive, physical, and visual ability, and that a prescriber’s order for self-administration and bedside storage must be present in the medical record and reflected on the MAR and medication label. For the resident in question, who had diagnoses including cerebral infarction, major depressive disorder with psychotic symptoms, PTSD, hemiplegia and hemiparesis, speech and language deficits, and cerebral atherosclerosis, the EHR showed no assessment for self-administration and no physician order for self-administration or bedside storage, despite active ophthalmic medication orders. The resident’s MDS documented intact cognition with a BIMS score of 15, use of corrective lenses, and functional limitations in range of motion on one side of both upper and lower extremities. Surveyor observations on two consecutive days found an open box of lubricant eye drops on the resident’s bedside table. Staff interviews revealed inconsistent understanding and enforcement of the facility’s policies. A CNA stated that residents did not self-administer medications and that only nurses administered them, but also reported that when she previously reported the eye drops, she was told the resident could have them because he was independent. The Infection Preventionist acknowledged the resident had an order for eye drops and believed he obtained them from the VA, and stated he should not have the lubricant eye drops because they were a hazard for other people. The Administrator confirmed that typically a resident with medications at the bedside should be assessed for self-administration and stated the resident should not have eye drops in his room. The report notes that unsecured medications at the bedside had the potential to cause adverse reactions if accessed or ingested by other residents.
Failure to Maintain Safe and Clean Ceiling Surfaces Throughout Facility
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable homelike environment as required by its Maintenance Service policy, which assigns the Maintenance Department responsibility for keeping the building in good repair and free from hazards. Surveyors observed multiple stained and damaged ceiling tiles in several areas of the facility, including near the nurses' station, in a resident bedroom (room [ROOM NUMBER]A), in the glass day room, and in the middle of the east hall. On several occasions, ceiling tiles near the nurses' station were noted to have tannish-brown circular stains of varying sizes, and at one point a white, moldy substance was observed on a ceiling tile in that same area. In room [ROOM NUMBER]A, surveyors observed brown rings roughly 16 inches in diameter on ceiling tiles located directly above a resident’s bed, with the Maintenance Director later confirming that these tiles were stained, bulging, and at risk of falling on the resident. Additional observations in the glass day room identified two stained ceiling tiles above a resident’s chair, each with brown circular stains approximately three inches in diameter. In the east hall, a ceiling tile with a brown circular stain approximately 10 inches in diameter was also documented. The Maintenance Director and the Administrator both acknowledged that the stains and damage were related to roof leaks associated with recent rainfall, and the Administrator confirmed awareness of roof leaks that had previously been repaired and that the brownish stains were due to recent rain.
Failure to Prevent Sexual Abuse of a Cognitively Impaired Resident by Another Resident
Penalty
Summary
The facility failed to protect a dependent, cognitively impaired resident (R113) from sexual abuse by another resident (R12). R113 had severe cognitive impairment with a BIMS score of 5, was on hospice care, and was fully dependent for toileting, bathing, dressing, footwear, and personal hygiene. On the day of the incident, a CNA observed R12 in R113’s room with his right hand inside R113’s pants while she was seated in a geriatric chair. Staff witness statements and nursing progress notes documented that R12 was found in R113’s room with his hand in her pants, and the facility’s investigation substantiated that R12 touched R113 inappropriately. R12 also had severe cognitive impairment with a BIMS score of 4 and multiple psychiatric and dementia-related diagnoses, including vascular dementia with mood disturbance, Alzheimer’s disease, major depressive disorder, obsessive-compulsive personality disorder, unspecified psychosis, and unspecified mood affective disorder. He required extensive physical assistance, used a manual wheelchair, and was fully dependent for toileting, bathing, lower body dressing, and footwear. R12’s care plan, in place since 2017, identified him as having sexually verbally and physically inappropriate behavior, including documented prior incidents in which he inappropriately touched or attempted to touch female residents. His care plan included interventions such as discussing his behavior when reasonable, explaining that it was inappropriate, intervening to protect others, diverting his attention, and removing him from situations as needed, as well as monitoring and recording occurrences of target behaviors such as sexual aggression toward others. Despite this known history of sexually inappropriate behavior toward female residents and the presence of care plan interventions, R12 was able to enter R113’s room and place his hand inside her pants. The Administrator confirmed that the CNA reported finding R12 in R113’s room with his hand in her pants while R113 was in her wheelchair, and that the facility’s investigation substantiated the abuse allegation. The facility’s abuse policy stated that it would not condone resident abuse by anyone, including other residents, and defined sexual abuse to include sexual harassment, sexual coercion, or sexual assault. The occurrence of this incident demonstrated that the facility did not effectively prevent sexual abuse of R113 by another resident, despite R12’s documented behavioral history and existing care plan.
Failure to Develop and Implement Complete Care Plans for Antipsychotic Use and Foley Catheter Management
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for identified resident needs, as required by its Comprehensive Care Plan policy. The policy states that care plans must address all needs identified in the comprehensive assessment, including medical, nursing, mental, and psychosocial needs, and must be developed within seven days after completion of the comprehensive MDS assessment. It also requires that all triggered Care Area Assessments (CAAs) and other factors identified by the IDT or resident preferences be incorporated into the plan of care. For one resident, R44, the clinical record showed physician orders for Haloperidol 10 mg by mouth twice daily for schizophrenia, along with orders for behavior monitoring and psychiatric medication side effect monitoring. Despite these orders, the resident’s care plan dated 03/11/2026 did not include any care plan addressing antipsychotic medication use or its indication. The MDS Coordinator stated that all residents receiving antipsychotic treatment should have a comprehensive care plan in place beginning with the date the medication was originally ordered, and upon review of the record confirmed that such a care plan was not present for this resident at the time of the survey. For another resident, R3, the care plan dated 03/13/2026 identified a problem of an indwelling catheter secondary to neurogenic bladder related to prostate cancer, with goals including remaining free from catheter-related trauma. The listed interventions included positioning the catheter bag and tubing below bladder level, monitoring and documenting intake and output per policy, and monitoring for pain, discomfort, and signs and symptoms of UTI. However, the care plan did not address the amount of water in the catheter balloon, use of a leg strap or securement device, or other securement measures. Physician orders specified checking a leg strap every shift and documented that the resident was admitted with an 18F catheter attached to a bedside drainage bag, but observations showed the Foley catheter positioned under the resident’s leg without a leg strap or securement device on two occasions, and a CNA reported being unaware that a leg strap was required. The MDS Coordinator confirmed that these ordered interventions were missing from the care plan.
Failure to Revise Care Plan for Ongoing Smoking Policy Noncompliance
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive care plan to reflect current interventions implemented in response to ongoing noncompliance with the facility’s non‑smoking policy. The facility’s policy requires that the comprehensive care plan be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment, and that it include measurable objectives, timeframes, and alternative interventions as needed, with qualified staff notified when changes are made. The resident’s care plan included a focus on resistiveness to care and noncompliance with smoking, noting that the resident continued to go outside beyond facility property to smoke, and an intervention to review the smoking policy with the resident. Another care plan focus identified the resident as a smoker requiring supervision while smoking, with interventions stating the resident required supervision while smoking and that the charge nurse should be notified if a smoking policy violation was suspected. Despite repeated and ongoing noncompliance with the non‑smoking policy, the care plan was not revised to include additional interventions that were actually implemented. These unreflected interventions included daily room searches for smoking paraphernalia, placement of a smoke detector in the resident’s room, relocation of the resident’s room closer to the nursing station, every‑two‑hour visual rounds to check for smoke, nursing checks upon return from outings, initiation of a Patient at Risk (PAR) process for vaping noncompliance, and issuance of a 30‑day discharge notice for repeated violations of the non‑smoking policy. Documentation on the Smoking Materials Monitoring Form showed initials on selected days only, indicating daily room searches were not consistently completed and documented for the entire month. The PAR Smoking Tracking form documented multiple observations of vaping in the room, repeated room checks, removal of vapor devices, and the resident’s refusal to comply with facility policies, with later weeks lacking IDT signatures and documentation, while the PAR Grid showed multiple prior entries for violating the non‑smoking policy.
Failure to Control Smoking and Vaping Hazards for a Noncompliant Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision for a resident with a known history of noncompliance with the facility’s non‑smoking policy. The facility’s Smoking Policy requires that residents not be allowed to keep cigarettes, cigars, pipes, matches, or lighters in their possession or rooms, and that non‑compliant smokers receive daily searches with documentation, while compliant smokers receive weekly searches. The policy also requires incident reports and review in a “Patients at Risk” process whenever smoking materials are found. Despite these written procedures, the resident’s Smoking Materials Monitoring Form for April showed multiple days without documented searches, indicating that required daily room searches were not consistently completed or recorded. The resident at issue was cognitively intact, with a BIMS score of 15, and had significant physical impairments including hemiplegia and hemiparesis on the left side, use of a manual wheelchair, and other neurologic and psychiatric diagnoses such as cerebral aneurysm, cerebral infarction, major depressive disorder with psychotic symptoms, PTSD, and speech and language deficits. The care plan identified the resident as resistive to care and noncompliant with smoking, noting that he continued to go outside beyond facility property to smoke, and also identified him as a smoker requiring supervision while smoking. Progress notes and Patient at Risk documentation showed a pattern of repeated violations of the non‑smoking policy, including multiple instances of vaping and smoking in his room, with staff repeatedly finding vape devices and other smoking paraphernalia in his possession and in his room. Throughout the period reviewed, staff observations and interviews confirmed ongoing noncompliance with the smoking policy and inconsistent implementation of the facility’s own interventions. Staff documented several occasions when the resident was observed vaping or smoking in his room, including in the presence of a state surveyor, and room searches revealed multiple vape devices hidden under the sheets. Staff interviews indicated that daily room checks were not always performed due to competing demands, that logs of every‑two‑hour rounds were not maintained, and that there was confusion or inconsistency regarding whether the resident could keep items such as air freshener at bedside. The social worker, Infection Preventionist, MDS coordinator, Activities Director, CNA, and Administrator all acknowledged that the resident’s room had to be searched for cigarettes and vaping paraphernalia and that prohibited items were repeatedly found, while documentation showed gaps in the required daily searches and incomplete follow‑through on the Patient at Risk tracking process. These actions and inactions resulted in the environment not being kept free from accident hazards as required by the facility’s policy and regulatory standards. The deficiency is further supported by the facility’s own records showing repeated entries on the Patient at Risk grid for violations of the non‑smoking policy over an extended period, as well as narrative notes describing the resident’s statements that he would continue to vape in his room and would simply obtain new devices if they were confiscated. Despite the known pattern of behavior and the facility’s policy requiring close supervision, daily searches, and thorough documentation for non‑compliant smokers, the monitoring forms and staff interviews demonstrate that these measures were not consistently carried out. The presence of multiple vape devices and cans of air freshener at the bedside during surveyor observations, along with staff acknowledgment that room checks were missed and that logs of frequent rounds were not kept, illustrate the facility’s failure to effectively implement its own safety procedures to prevent accident hazards related to smoking and vaping in the resident’s room.
Unlocked and Unattended Treatment Cart with Topical Medications
Penalty
Summary
Surveyors identified a deficiency related to medication storage when a treatment cart containing topical medications was left unlocked and unattended in a hall. The facility’s policy titled “Medication Storage in the Facility,” effective 10/01/2025, states that the medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff lawfully authorized to administer medications, and that medication rooms, carts, and supplies are to be locked or attended by authorized personnel. During an observation on 04/29/2026 at 9:35 AM, after wound care was provided to resident R3 by the wound care LPN, the treatment cart was observed left in the [NAME] hall across from R3’s room, unlocked and unattended for 30 minutes. In an interview, the wound care LPN confirmed that the treatment cart had been left unlocked and unattended. The Infection Preventionist LPN later confirmed that the wound care nurse told her the cart was left unlocked, and the Administrator stated that her expectation was that all medications, including topical medications, be locked when not in sight of a licensed nurse or authorized person. This deficient practice occurred in a facility with a census of 94 residents and involved the failure to follow the facility’s own policy requiring that medication carts be locked or attended by authorized personnel, resulting in unsecured access to topical medications on the treatment cart.
Failure to Implement Legionella Water Management and Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to provide and implement an infection prevention and control program, including a documented water management plan for Legionella and other waterborne pathogens, and a fully implemented Enhanced Barrier Precautions (EBP) program. The Administrator stated there was no Legionella water program in place, and the Maintenance Supervisor reported he was unaware of the requirement for such a program. This was despite the existence of a written Legionella Water Management Program policy, revised in September 2022, which described the need for an interdisciplinary water management team, detailed water system diagrams, identification of risk areas and situations for Legionella growth, control measures, monitoring systems, and annual review. Interviews confirmed that the expectation was that the facility would be conducting this water program, but it was not being done. The facility also failed to implement EBP for residents with indwelling medical devices and other risk factors, as required by its own policy. One resident with Alzheimer’s disease, urinary obstruction, and emphysema had an indwelling urinary catheter documented in the care plan and physician orders, but the care plan did not address EBP related to the catheter, and there was no order for EBP in the record. During catheter-related care, a CNA wore gloves but did not wear a gown, and there was no EBP signage or PPE setup at the room. Multiple staff members, including CNAs and a housekeeper who regularly worked on the resident’s hallway, reported they did not know what EBP was or incorrectly associated EBP only with residents on Transmission-Based Precautions. The DON acknowledged that an attempt to roll out EBP months earlier had not been completed, and that expected signage and PPE caddies for EBP were not fully in place. Additional infection control lapses were observed during tube feeding care and contact isolation. A resident receiving continuous tube feeding had a care plan and physician’s order for enteral nutrition, and an LPN initiated the feeding while wearing gloves but no gown. During the procedure, the LPN repeatedly touched her hair with the same gloved hands and then handled the feeding tube, pump, and syringe used to inject air and check residuals, only removing gloves and using hand sanitizer at the end. The LPN later acknowledged she should have changed gloves after touching her hair and stated she did not know what EBP was or that a gown was required for feeding tube care, while another LPN and the IP stated that EBP with gown and gloves should be used for feeding tube care and that staff should not touch their hair during care without changing gloves and performing hand hygiene. For a resident with a positive urine culture and a subsequent positive C. difficile culture who was on isolation, the door sign indicated isolation but did not provide instructions for visitors on required precautions or direct them to staff for guidance. The IP confirmed there was no system to direct visitors about PPE use for residents on contact isolation and acknowledged that visitors would not know to wear PPE if it was simply present in or on the door of the room. Overall, the survey findings show that the facility did not operationalize its written Legionella water management policy and did not consistently apply its EBP policy for residents with indwelling devices or wounds. Staff interviews and observations demonstrated a lack of knowledge and implementation of EBP, incomplete use of PPE during high-contact care activities such as catheter care and tube feeding, and unclear isolation signage that did not instruct visitors on appropriate precautions. These combined inactions and omissions in policy implementation, staff education, and practice led to the cited infection prevention and control deficiency.
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