Woodstock Center For Nursing And Healing Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Woodstock, Georgia.
- Location
- 105 Arnold Mill Road, Woodstock, Georgia 30188
- CMS Provider Number
- 115421
- Inspections on file
- 22
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Woodstock Center For Nursing And Healing Llc during CMS and state inspections, most recent first.
A resident with paranoid schizophrenia and known behavioral disturbances verbally threatened another resident with violent, profane language in the activities room, leaving the threatened resident confused. The aggressor resident had a documented history of potential for verbal abuse related to mental illness and psychotropic medication use, as well as non‑compliance with medications, yet was still able to direct a specific threat toward another resident. The facility’s investigation substantiated this as an incident of verbal abuse, despite an existing policy prohibiting abuse, neglect, and exploitation.
An LPN signed out controlled medications for three residents in the narcotic log as if administered, but the residents either reported not receiving their scheduled pain or anxiety medications or had documentation indicating late or missing doses. For one resident with chronic back pain on scheduled morphine and another with vertebral fracture and arthritis on scheduled tramadol, the MAR showed the drugs initialed as given, yet there was no clear documentation of the actual administration time or explanation for the missed or delayed doses, and one resident’s pain scores were inconsistently charted. A third resident with anxiety on scheduled alprazolam had the drug signed out in the narcotic book and initialed on the MAR, but progress notes indicated it was not properly signed off in the EMAR. The LPN later stated that, after being asked to leave the facility because she was not formally assigned to the shift, she discarded the medications without a witness, contrary to facility policy requiring two licensed staff to witness and document controlled substance disposal, resulting in discrepancies between the narcotic log and MAR.
Staff did not consistently keep garbage dumpster lids closed and failed to maintain cleanliness around the dumpsters, leaving debris such as used gloves on the ground. Multiple observations confirmed that dumpster doors were left open when not in use, contrary to facility policy, and staff interviews acknowledged responsibility for these tasks.
A review of facility records and staff interviews revealed that the facility did not maintain a surety bond sufficient to cover all resident personal funds on deposit, with account balances exceeding the bond amount for several months. This failure affected the security of personal funds for multiple accounts managed by the facility.
Staff did not consistently provide or document required ADL assistance for three residents with significant cognitive and physical impairments. One resident was left in soiled linens without timely incontinence care, another had persistently dirty and untrimmed fingernails despite documentation suggesting care was provided, and a third had no records of receiving showers or bed baths for an extended period, even after a family grievance. Interviews revealed inconsistent practices and incomplete documentation among CNAs and nursing staff.
A resident with severe cognitive impairment and multiple medical conditions did not consistently receive physician-ordered TED hose as required, despite documentation in the MAR indicating otherwise. Observations showed the resident without the compression stockings during required times, and staff interviews revealed that LPNs sometimes documented the task as completed without actually applying the hose, with one LPN unaware of the order. The DON confirmed that documentation should reflect real-time care provided.
The facility had a medication administration error rate of 6.45%, exceeding the acceptable limit of 5%. An LPN failed to administer furosemide to a resident and did not perform required respiratory assessments for another resident receiving a nebulizer treatment. The DON confirmed these lapses in protocol.
The facility failed to protect residents from sexual abuse by other residents. One resident was groped by another in a common area, and another resident placed their hand down a different resident's shirt in the dining room. Both incidents involved residents with cognitive impairments and dependency on staff for ADLs. Despite regular staff training on abuse prevention, the facility's measures were insufficient to prevent these occurrences.
A resident with significant medical conditions and dependence on staff for personal hygiene did not receive adequate shower assistance, as documented in the EMR and confirmed through interviews. The DON acknowledged the lack of a dedicated shower team and inconsistent adherence to shower schedules.
A resident with respiratory failure was observed receiving O2 at 3.5 LPM despite a physician's order for 1 LPM. This discrepancy was confirmed by both an LPN and an RN/UM, who acknowledged the physician's order and the current O2 setting. The resident was alert and had no complaints about the care received.
The facility failed to secure resident medications as two medication carts and an IV cart were found unlocked and unattended. Staff confirmed that the carts should not have been left unlocked, and the DON reiterated that medication carts must always be locked when not attended.
The facility failed to properly perform infection control practices during medication administration. One LPN did not disinfect an electronic blood pressure cuff between uses on different residents, and another LPN handled medication with ungloved hands. The DON confirmed that these actions were against the facility's infection control policies.
Failure to Prevent Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to protect a resident from verbal abuse when one resident threatened another with violent language. One resident (R7), who had paranoid schizophrenia, used a wheelchair, and had a BIMS score of 15/15 indicating little to no cognitive impairment, told another resident (R8), "I will blow your brains out" with profanity while in the activities room. R8, who had type 2 diabetes, leg pain, unilateral primary osteoarthritis, and a BIMS score of 8/15 indicating moderate cognitive impairment, reported hearing R7 rambling, not understanding what was said, and then hearing the explicit threat directed at her. R8 stated she felt confused afterward. The facility’s own investigation, as documented in the Incident Summary Report, substantiated the allegation of verbal abuse. R7’s care plan, in place prior to the incident, documented that she used psychotropic medications with potential effects on mood and behavior and that she had the potential to demonstrate verbal abuse related to her mental and emotional illness, including paranoid schizophrenia. The NP noted that R7 continued to demonstrate behavioral disturbances, was verbally abusive at times, and was non‑compliant with her medication regimen, though she had not been physically threatening. The DON confirmed familiarity with R7’s history of increased hallucinations, paranoia, and verbal abuse when medication adjustments were needed. Despite this known risk and the facility’s written policy prohibiting abuse, neglect, and exploitation, R7 was able to verbally abuse R8, resulting in a substantiated incident of resident‑to‑resident verbal abuse.
Misappropriation and Poor Accountability of Controlled Medications
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from misappropriation of medications, specifically controlled substances, and to ensure accurate administration and documentation for three residents. For one resident with chronic pain, muscle spasm, spinal stenosis, osteoarthritis, hypertension, and Alzheimer’s disease, the MDS showed moderate cognitive impairment and ongoing pain requiring scheduled Morphine Sulfate ER 15 mg twice daily. On the date in question, an incident report documented that the DON was notified that this resident and others had not received their scheduled 9:00 AM narcotic medications. The narcotic book showed that an LPN had signed out the Morphine as if administered, but the resident later verbalized that the morning dose had not been received. For a second resident with cerebral infarction, vertebral fracture, arthritis, and hypertension, the MDS indicated moderate cognitive impairment and frequent, almost constant pain that interfered with daily activities, with an order for Tramadol 50 mg twice daily. The incident report again showed that the DON was notified that this resident had not received the scheduled 9:00 AM narcotic medication, while the narcotic book reflected that the LPN had signed out the Tramadol as administered. Review of the MAR for that date revealed conflicting pain scores of 0 and 9 and showed Tramadol initialed as given at 9:00 AM, but there was no documentation of the actual time of administration or explanation for the delayed or missed dose. A progress note indicated that Tramadol was signed out in the narcotic book but not signed off on the MAR. For a third resident with major depressive disorder, anxiety, gout, and psoriasis, the MDS showed little to no cognitive impairment and frequent pain, and the resident had an order for Alprazolam 0.5 mg once daily for anxiety. The incident report documented that the DON was notified that this resident had not received the scheduled 9:00 AM anxiety medication, even though the narcotic book showed the LPN had signed out the Alprazolam as if given. The MAR showed Alprazolam initialed as administered at 9:00 AM, but there was no documentation of the actual time of administration or any accounting for the delayed or missed dose. Progress notes for this resident stated that the medication was not signed off on the EMAR but was signed off in the narcotic book as given at 9:00 AM. Across all three residents, the LPN initially confirmed administration of the medications but later stated that, after being asked to leave the facility because she was not formally assigned to the shift, she discarded the medications without a witness, contrary to facility policy requiring two licensed staff to witness and document any controlled substance disposal. The facility’s written policy on Controlled Substance Administration & Accountability stated that the Controlled Drug Record serves the dual purpose of recording both narcotic disposition and patient administration and, together with the MAR, is the source for documenting any patient-specific narcotic dispensed from the pharmacy. The policy also required that two licensed staff witness any disposal or destruction of a controlled substance and document it on the Drug Disposition Record. In these incidents, controlled substances were signed out in the narcotic log as if administered, residents reported or were documented as having missed or late doses, and there was no proper witnessing or documentation of disposal, resulting in discrepancies between the narcotic log, MAR, and resident reports.
Improper Disposal and Maintenance of Garbage Dumpsters
Penalty
Summary
Staff failed to properly dispose of garbage and refuse in accordance with the facility's policy, which requires dumpsters to be kept covered when not being loaded and the surrounding area to be kept clean. During multiple observations, surveyors noted that the sliding lids of both garbage dumpsters were left open when not in use, and there was debris, including used gloves and other materials, on the ground around the dumpsters. Interviews with the Administrator and Dietary Manager confirmed that staff were responsible for closing the dumpster doors and maintaining cleanliness, but these procedures were not consistently followed, as evidenced by repeated observations of open dumpster doors and debris present in the area. No information about residents or their medical conditions was included in the report, and the deficiency was based solely on staff actions and facility practices related to waste disposal.
Insufficient Surety Bond for Resident Personal Funds
Penalty
Summary
The facility failed to assure the security of all personal funds deposited by residents by not maintaining a sufficient surety bond to cover the total amount of resident funds managed. Review of the facility's policy on Resident Personal Funds indicated that a surety bond or other satisfactory assurance must be in place to secure all resident funds. Examination of bank statements over a six-month period showed that the facility held resident funds exceeding $100,000, with balances ranging from $106,898.12 to $133,831.89 during several months. However, the surety bond in effect during this period was only $100,000, which was not adequate to cover the highest balances held in resident accounts. Interviews with the Administrator and the Director of Regulatory Compliance (DRC) confirmed that the surety bond should be sufficient to cover the total balance of resident funds. The DRC later provided documentation of an increased surety bond amounting to $150,000, but this updated bond only became effective after the period in question and did not retroactively cover the higher balances previously held. As a result, the security of personal funds for 56 accounts managed by the facility was not fully assured during the months when the resident fund balances exceeded the surety bond amount.
Failure to Provide Required ADL Assistance and Documentation
Penalty
Summary
Staff failed to provide necessary assistance with activities of daily living (ADLs) for three residents who required support due to various medical conditions. One resident with dementia, diabetes, and limited mobility was observed sitting on soiled linens with urine-soaked clothing, despite care plans indicating the need for regular incontinence care and staff checks every two hours. The Director of Nursing confirmed that all nursing staff were responsible for providing this care. Another resident with a history of cerebral infarction, hemiplegia, and vascular dementia was found to have untrimmed and dirty fingernails on multiple occasions, even though documentation on shower sheets indicated that nail care was performed. Interviews with CNAs revealed inconsistencies in nail care practices and documentation, with one CNA expressing discomfort in trimming nails and deferring the task to nursing staff, but without clear follow-up or documentation. A third resident with severe cognitive impairment, Alzheimer's disease, and a history of falls had no documented evidence of receiving showers or bed baths for two months, despite care plans and a grievance from the resident's daughter regarding the resident being wet and needing clean linen. Staff interviews indicated that showers and bed baths were to be provided and documented, but records for the relevant months were missing, and there was no confirmation that the required ADL care was delivered.
Failure to Apply and Accurately Document Physician-Ordered TED Hose
Penalty
Summary
Facility staff failed to follow a physician's order for a resident requiring TED hose (compression stockings) to be applied to both lower extremities each morning when out of bed and removed at bedtime. Despite documentation in the Medication Administration Record (MAR) indicating that the TED hose were applied daily, multiple observations revealed that the resident did not have the TED hose on during the required times. The resident, who was severely cognitively impaired and had diagnoses including cerebral infarction, hemiplegia, and lower leg atrophy, was observed attempting to communicate the need for the TED hose and was seen retrieving them from a drawer himself. Staff interviews confirmed that the TED hose were not consistently applied as ordered. Further review of facility policies showed requirements for accurate and objective documentation, and for staff to sign the MAR only after administration of care or medication. However, interviews with LPNs revealed that staff sometimes documented the application of the TED hose without actually performing the task, with one LPN admitting to marking the MAR without having put on the hose and another stating she was unaware of the order for the TED hose. The Director of Nursing confirmed that it was expected for staff to document care in real time and not to mark tasks as completed if they had not done them.
Medication Administration Errors and Policy Violations
Penalty
Summary
The facility failed to ensure that the medication administration error rate was less than 5%, resulting in an observed error rate of 6.45%. During medication administration, an LPN prepared medications for a resident but did not administer furosemide because it was not available. The LPN stated that the medication could be pulled from the automated medication dispensing system but did not do so, leading to the resident missing a dose. The Director of Nursing confirmed that the medication was available in the system and should have been administered to the resident. Another incident involved the same LPN administering medications to a different resident, including a nebulizer treatment. The LPN used a Flonase nasal spray that was not labeled with the resident's name and left the resident unattended during the nebulizer treatment. Additionally, the LPN did not assess the resident's respiratory status before and after the nebulizer treatment, contrary to the facility's policy. The Director of Nursing confirmed that respiratory assessments should be conducted and documented for nebulizer treatments.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect the residents' right to be free from sexual abuse by other residents. Specifically, one resident (R52) was groped by another resident (R51) in a common area, and another resident (R270) placed their hand down a different resident's (R8) shirt in the dining room. Both incidents were documented in Facility Incident Report Forms and involved residents with varying degrees of cognitive impairment and dependency on staff for activities of daily living (ADLs). The facility's policy on abuse prevention was not effectively implemented to prevent these incidents from occurring. The first incident involved R51, who has severe cognitive impairment and requires substantial assistance with ADLs, groping R52, who also has severe cognitive impairment and is dependent on staff for most ADLs. The second incident involved R270, who has little or no cognitive impairment but is dependent on staff for ADLs, placing their hand inside R8's shirt. Both incidents were reported to the state and investigated per facility policy. Staff interviews confirmed that they received regular training on abuse prevention and dementia care, and were aware of the procedures for reporting abuse. However, the facility's measures were insufficient to prevent these occurrences of resident-to-resident sexual abuse.
Failure to Provide Adequate Shower Assistance
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) assistance, specifically showers, for a resident (R35) who was dependent on staff for personal hygiene. R35, who had diagnoses including spina bifida, neurogenic bowel, neuromuscular dysfunction of the bladder, and Fournier gangrene, was documented as having little or no cognitive impairment and no behavioral issues. Despite being dependent on staff for bathing, the electronic medical record (EMR) and shower sheets revealed that R35 was only given a shower on five occasions between March and April 2024. Interviews with R35 confirmed that he had not received a shower for two weeks as of mid-May 2024. The Director of Nursing (DON) acknowledged that there was no dedicated shower team, but staff were assigned to give showers daily. However, there were no routine showers scheduled for the night shift unless requested by residents. The DON also stated that if a resident refused a shower, staff would document the refusal and offer the shower again at a different time. Despite these protocols, R35 reported not receiving a shower while his roommates did, indicating a failure in the facility's adherence to its own policies and the resident's care plan, which required extensive assistance with bathing.
Failure to Follow Physician Orders for Oxygen Administration
Penalty
Summary
The facility failed to follow physician orders related to oxygen (O2) liter flow for a resident with respiratory failure. The resident, who had a physician's order for O2 at 1 liter per minute (LPM) via nasal cannula (NC) to keep O2 saturation above 92%, was observed on multiple occasions receiving O2 at 3.5 LPM. This discrepancy was confirmed by both a Licensed Practical Nurse (LPN) and a Registered Nurse (RN)/Unit Manager (UM), who acknowledged the physician's order and the current O2 setting. The resident was alert, oriented, and had no complaints about the care received during the observations. However, the facility's failure to adhere to the prescribed O2 flow rate was evident. The resident's electronic medical record (EMR) indicated a history of unspecified respiratory failure and a personal history of COVID-19. The care plan for the resident included O2 therapy to maintain O2 saturation above 92% and monitoring for abnormal breathing patterns. Despite these documented interventions, the resident was consistently provided with a higher O2 flow rate than ordered. The RN/UM mentioned that in cases where a resident needed more O2, the provider would be notified to adjust the order, but there was no indication that such a notification had occurred in this instance.
Failure to Secure Medication Carts
Penalty
Summary
The facility failed to safely secure resident medications as evidenced by the observation of two of six medication carts left unlocked and unattended. During an initial tour, the C-Hall (300 hall) medication cart was found unlocked and unattended in the hallway. Upon return, RN QQ admitted that the cart should not be left unlocked but explained it was due to the cart being shared between two charge nurses, with the key left in the narcotic count book for access. Similarly, the B-Hall (200 hall) medication cart was also found unlocked and unattended, and LPN NN confirmed that it should not have been left unlocked. Additionally, the IV cart was noted to be unlocked and this was verified by the Unit Manager. The Director of Nursing (DON) confirmed during an interview that medication carts should always be locked when not attended, especially during the night shift. The facility's policy titled 'Storage of Medications' mandates that all compartments containing drugs and biologicals must be locked when not in use and should not be left unattended if open or potentially available to others. The failure to adhere to this policy resulted in unauthorized access to resident medications, posing a potential risk to residents, staff, and visitors.
Infection Control Deficiencies During Medication Administration
Penalty
Summary
The facility failed to properly perform infection control practices during medication administration, as observed in the actions of two Licensed Practical Nurses (LPNs). One LPN did not disinfect an electronic blood pressure cuff between uses on different residents. Specifically, the LPN checked the vital signs of one resident, placed the cuff back on the medication cart, and then used the same cuff on another resident without cleaning it. When questioned, the LPN admitted forgetting to clean the cuff, despite knowing it was required to prevent cross-contamination between residents. Another LPN was observed handling medication with ungloved hands. This LPN poured Tylenol pills into the lid of the bottle, used her bare hand to hold an extra pill, and then placed the extra pill back into the bottle. She also counted the pills by pouring them onto a tissue and then picked them up with her bare hand to place them back into the medication cup. When asked, the LPN believed it was acceptable to touch the pills with bare hands if hand sanitizer was used beforehand. The Director of Nursing confirmed that the staff were expected to clean the blood pressure cuff after each use and that nurses should not handle pills with bare hands, even if hand hygiene was performed.
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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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