Westbury Center Of Conyers For Nursing And Healing
Inspection history, citations, penalties and survey trends for this long-term care facility in Conyers, Georgia.
- Location
- 1420 Milstead Road, Conyers, Georgia 30012
- CMS Provider Number
- 115469
- Inspections on file
- 23
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Westbury Center Of Conyers For Nursing And Healing during CMS and state inspections, most recent first.
A resident with bowel and bladder incontinence, UTI, muscle weakness, and moderately impaired cognition required staff assistance for toileting hygiene and perineal care. During observed incontinence care, a CNA changed gloves without performing required hand hygiene between glove removal and donning new gloves, contrary to the facility’s infection prevention and control and hand hygiene policies. In interviews, the CNA, SDC, and DON all confirmed that hand washing or sanitizing is expected between glove changes and that not doing so can lead to spread of germs, cross-contamination, or infection.
A resident with upper extremity impairment and total dependence for care was not provided with a call device she could use, despite staff awareness of her inability to activate the standard call light. The care plan did not address her needs, and no appropriate assessment or device was provided, leaving her unable to independently request assistance.
A resident who was not cognitively intact was transferred to a hospital on two occasions without being provided a written bed hold notice or reason for transfer, as required by facility policy. The resident's representative confirmed not receiving the notice, and staff interviews revealed confusion over who was responsible for providing and documenting the bed hold information. No documentation was found in the resident's record to show that the required notice was given.
The facility's medication error rate exceeded 5% due to two incidents: an LPN crushed and administered atorvastatin calcium tablets to a resident with kidney and neurological conditions, despite this being contraindicated, and another LPN gave two scoops of polyethylene glycol to a resident with neurological deficits instead of the prescribed one scoop, based on the resident's request and without provider approval.
A resident with a history of medical conditions was in visible distress and pain, yet the facility staff failed to provide adequate pain management. Despite having an order for a stronger medication, only Tylenol and Zofran were administered, which were ineffective. The resident's condition worsened throughout the day, and she was eventually sent to the hospital with a diagnosis of colitis. Interviews revealed a lack of urgency in addressing the resident's needs, leading to actual harm.
The facility inaccurately reported staffing data to CMS for Q1 2024, resulting in a One-Star Staffing Rating. The PBJ report showed issues such as missed deadlines, insufficient RN staffing hours, and audit failures. The facility's assessment recommended four RNs for its 173-bed capacity and 145 average daily census. The DON and Administrator acknowledged the rating, citing high turnover and agency reliance.
A medication error rate of 11.11% was identified when an LPN administered medications to a resident with hypertension and cerebral infarction too early, outside the facility's policy of a 60-minute window around the scheduled time. The LPN adjusted the timing for residents in the skilled hall, and the ADON confirmed the error, noting that exceptions require physician approval.
A facility failed to ensure consistent documentation of a resident's code status, with discrepancies between the EMR, physician orders, and POLST. Staff interviews revealed confusion, as the EMR and orders indicated a DNR status, while the POLST showed a Full Code. The DON confirmed the expectation for consistent documentation, which was not met.
A resident with contracted hands did not receive adequate ADL care, resulting in poor nail care and hand hygiene. Despite being cognitively intact and dependent on staff for ADL care, the resident expressed dissatisfaction with the care provided. Observations showed dirty and untrimmed nails, and staff interviews confirmed that the facility's ADL protocols were not followed, leading to unmet care needs.
A resident with a urostomy was sent to an outside appointment without a urostomy bag, as the facility ran out of supplies. The resident's stoma was covered with an adult brief and a disposable bed pad. The incident was reported by the resident's caseworker, and the facility staff explained that the resident had removed the appliance before leaving. The Administrator noted that the supplies were special-order items not available through usual resources.
The facility failed to follow infection control practices by not bagging a resident's C-PAP mask when not in use and an LPN handling medications with bare hands. The C-PAP mask was found unbagged on a resident's bed, contrary to policy, and the LPN admitted to touching medications with bare hands, which is against infection control protocols.
Failure to Perform Hand Hygiene Between Glove Changes During Incontinence Care
Penalty
Summary
The deficiency involves failure to follow the facility’s infection prevention and control and hand hygiene policies during incontinence care for one resident. The facility’s Infection Prevention and Control Program Description policy requires implementation of control measures and precautions, including hand hygiene, and the Hand Hygiene policy requires all staff to perform proper hand hygiene consistent with accepted standards of practice. The resident involved had diagnoses including contractures of both hands, UTI, and muscle weakness, with a BIMS score indicating moderately impaired cognition, and was care planned as bowel and bladder incontinent with staff responsible for cleaning the perineal area and changing briefs and clothing as needed after incontinence episodes. During observed incontinence care, a CNA did not perform hand hygiene between glove changes. The CNA acknowledged that she failed to sanitize her hands after removing used gloves and before donning a new pair and stated she should have done so. The SDC and DON both stated in interviews that staff are expected to wash or sanitize hands between glove changes and that failure to do so could result in spread of germs, cross-contamination, or infection to residents. These observations and interviews showed that staff actions during incontinence care did not comply with the facility’s established hand hygiene and infection control policies.
Failure to Provide Suitable Call Device for Dependent Resident
Penalty
Summary
A resident with a history of cervical spinal cord injury and schizophrenia, who was dependent for all activities of daily living and had upper extremity impairment, was not provided with a call device suitable for her use. Despite the call light being placed within her reach, the resident was unable to activate it due to her physical limitations, as observed on multiple occasions. Staff interviews confirmed awareness of the resident's inability to use the standard call button, and documentation revealed that the care plan did not address her inability to use the call device. The deficiency was further evidenced by the lack of an appropriate assessment upon admission to determine the resident's need for a specialized call device. Both nursing and administrative staff acknowledged that the resident required a different type of call light, but no suitable device was provided during the period reviewed. The resident had to wait for staff to check on her for assistance, as she could not independently call for help.
Failure to Provide Written Bed Hold Notice at Time of Hospital Transfer
Penalty
Summary
The facility failed to provide a written bed hold notice or reason for transfer to a resident and their representative at the time of two separate hospital transfers. According to the facility's own policy, written information regarding bed hold practices must be given both in advance and at the time of transfer for hospitalization or therapeutic leave. Record review showed that the resident was not cognitively intact at the time of the transfers, and there was no documentation in the clinical record that the required notices were provided for either transfer. Interviews with the resident's representative confirmed that no written bed hold notice was received, and this was the first time the representative had heard of the term 'bed hold.' Staff interviews revealed confusion and lack of clarity regarding responsibility for providing and documenting the bed hold notice. Nursing staff believed the business office or admissions was responsible, while the business office manager stated it was the nursing staff's duty to provide the notice at the time of transfer. The unit manager indicated that providing the bed hold policy was part of the transfer process, but acknowledged there was no documentation of this action. The administrator was unable to locate any proof that the required written notice was given for the hospital transfers, despite expectations that nursing staff would provide and document the notice in the resident's record.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, as required by policy, resulting in a calculated error rate of 7.69 percent. This was determined through observations, staff and resident interviews, and record reviews. For one resident with diagnoses including hyperkalemia, acute kidney failure, and encephalopathy, an LPN crushed and administered atorvastatin calcium oral tablet, despite the medication not being approved for crushing. The LPN acknowledged the error, and the facility pharmacist confirmed that atorvastatin calcium tablets should not be crushed. The Director of Nursing also confirmed that nurses are expected to follow the facility's policy and reference materials regarding medication administration. In another instance, a resident with a history of hemiplegia, hemiparesis, dysarthria, anarthria, and muscle weakness was ordered to receive one scoop of polyethylene glycol powder daily for constipation. However, an LPN administered two scoops after the resident requested an additional dose, without provider approval. The LPN confirmed the deviation from the physician's order, and the Director of Nursing stated that any changes to medication administration require prior provider approval. These actions directly contributed to the facility's medication error rate exceeding the acceptable threshold.
Failure in Pain Management for Resident
Penalty
Summary
The facility failed to provide adequate pain management for a resident, R117, who was in distress and exhibiting signs of pain. Despite having an active order for a stronger pain medication, Tramadol, the staff only administered Tylenol and Zofran, which were ineffective. Observations on the day of the incident revealed that R117 was in significant pain, rocking, moaning, and vomiting, yet the staff did not assess her condition adequately or administer the stronger medication available. The resident, R117, had a history of conditions including gastroparesis, diabetes, and systemic inflammatory response syndrome. Her care plan included interventions for pain management, but these were not followed. On the day of the incident, the LPN on duty prioritized medication pass over attending to R117's immediate needs, despite her visible distress and requests for assistance. The resident's condition worsened throughout the day, and she was eventually sent to the hospital with a diagnosis of colitis. Interviews with staff revealed a lack of urgency in addressing R117's pain and distress. The LPN initially dismissed the resident's request for help, and the Director of Nursing only intervened after being informed by the surveyor. The facility's failure to adhere to its pain management policy and to respond promptly to the resident's needs resulted in actual harm to R117, who was left in pain and distress for several hours before being sent to the hospital.
Inaccurate Staffing Data Reporting Leads to One-Star Rating
Penalty
Summary
The facility failed to accurately report direct care staffing data to the Centers for Medicare and Medicaid Services (CMS) for the first quarter of Fiscal Year 2024. This deficiency was identified through a review of the Payroll Based Journal (PBJ) report, which indicated a One-Star Staffing Rating due to several issues: failure to submit PBJ data by the deadline, more than four days in the quarter without Registered Nurse (RN) staffing hours, and failure to respond to or pass a CMS audit designed to discover discrepancies in PBJ data. The facility's assessment tool indicated a licensed bed capacity of 173 beds with an average daily census of 145 residents, recommending four RNs based on resident acuity levels. Interviews with the Director of Nursing (DON) and the Administrator revealed awareness of the staffing rating issue, attributing it to high turnover rates and reliance on staffing agencies.
Medication Administration Timing Error
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in an error rate of 11.11% during the survey. This deficiency was identified through observations, record reviews, and staff interviews. Specifically, the error involved the administration of medications to a resident, R124, who had diagnoses including hypertension and cerebral infarction. The medications, which included carvedilol, baclofen, and apixaban, were ordered to be administered at 9:00 am but were given at 7:13 am by an LPN, outside the facility's policy of administering medications within 60 minutes of the scheduled time. The LPN acknowledged administering the medications too early and stated she had adjusted the timing for residents in the skilled hall due to varying needs, such as pain management before therapy. The Assistant Director of Nursing confirmed that the administration time was incorrect and noted that exceptions to the timing policy should be documented and approved by a physician. The failure to adhere to the scheduled medication administration times as per the physician's orders and facility policy led to the identified deficiency.
Inconsistent Code Status Documentation for a Resident
Penalty
Summary
The facility failed to ensure that the code status for one of the residents, identified as R111, was consistently documented and available to the staff responsible for the resident's care. The facility's policy on Residents Rights Regarding Treatment and Advanced Directives requires that any decision-making regarding a resident's choices be documented in the medical record and communicated to the interdisciplinary team. However, there was a discrepancy in the documentation of R111's code status. The Electronic Medical Record (EMR) and physician orders indicated a Do Not Resuscitate (DNR) status, while the Physician Orders for Life Sustaining Treatment (POLST) documented a Full Code status, signed by two physicians and the resident's responsible party. Interviews with staff, including a Certified Nurse Aide (CNA), a Licensed Practical Nurse (LPN), a Hospice Registered Nurse (RN), and the Director of Nursing (DON), revealed inconsistencies in the understanding and documentation of R111's code status. The CNA and LPN referred to the EMR for code status information, which showed a DNR status, while the Hospice RN confirmed a Full Code status as per the POLST. The DON acknowledged the expectation for the code status to be easily located and consistent across the EMR, orders, and miscellaneous documents, which was not the case for R111.
Inadequate ADL Care for Resident with Contracted Hands
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) care for a resident with contracted hands, resulting in poor nail care and hand hygiene. The resident, identified as R4, was admitted with multiple diagnoses including chronic respiratory failure, chronic kidney disease, Alzheimer's disease, hypertension, chronic obstructive pulmonary disease, and a psychotic disorder. Despite being cognitively intact with a BIMS score of 15, R4 was dependent on staff for ADL care. The care plan indicated a self-care deficit requiring assistance with ADL care due to physical limitations and multiple comorbidities, with a preference for bed baths. Observations and interviews revealed that R4 had dirty fingernails digging into her skin and expressed dissatisfaction with the frequency and quality of care. On multiple occasions, R4 was observed with unclean hands and nails, and her fingernails were untrimmed and contracted into her skin. A CNA confirmed that ADL care should include hand and nail care, and a LPN stated that the facility's ADL protocols should encompass comprehensive hand cleaning, with only nurses permitted to cut nails if the resident is diabetic. The LPN confirmed that R4 prefers her nails short and clean, indicating a failure to meet the resident's care needs.
Failure to Provide Urostomy Care
Penalty
Summary
The facility failed to provide appropriate urostomy care for a resident, identified as R262, who was sent to an outside appointment without a urostomy bag. R262 had a urostomy with an ileal conduit due to bladder cancer and was admitted with diagnoses including malignant neoplasm of the posterior wall of the bladder and surgical aftercare of the genitourinary system. The care plan for R262 included interventions such as educating the resident on the importance of keeping a urostomy bag and providing urostomy care as ordered. However, on the day of the appointment, the resident was sent out without the necessary urostomy appliance, which was covered with an adult brief and a disposable bed pad instead. The incident was reported by the resident's caseworker, who informed the facility that Adult Protective Services had been notified. The facility's staff explained that the resident had removed the appliance before leaving and that there were no additional supplies available to reapply it. The Director of Nursing, who was not employed at the time of the incident, confirmed that residents should not be sent out without the appropriate ostomy bag. The Administrator stated that the resident's supplies were special-order items not available through the facility's usual supply resources, and the shipment had not arrived in time for the appointment.
Infection Control Deficiencies in Respiratory and Medication Handling
Penalty
Summary
The facility failed to adhere to standard infection control practices, as evidenced by two specific incidents. In the first incident, a continuous positive airway pressure (C-PAP) mask belonging to a resident was observed unbagged and lying on a towel on the resident's bed. The resident mentioned that he cleans the machine himself daily. A Licensed Practical Nurse (LPN) confirmed that the mask was not bagged, which was against the facility's policy that requires respiratory equipment to be covered in a plastic bag when not in use. Both the Director of Nursing and the Administrator stated that it is the responsibility of the nursing staff to ensure that C-PAP masks are clean and bagged when not in use. In the second incident, an LPN was observed handling medications with her bare hands during medication administration. The facility's policy explicitly states that medications should not be touched with bare hands to prevent contamination or infection. The LPN admitted to handling the medications with her bare hands, citing that her hands were too big and she did not want to drop the medications. The Assistant Director of Nursing confirmed that the expectation is for nurses to avoid touching medications with bare hands and to use gloves if necessary. These actions were in direct violation of the facility's infection control protocols.
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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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