Wrightsville Manor Health And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Wrightsville, Georgia.
- Location
- 337 West Court Street, Wrightsville, Georgia 31096
- CMS Provider Number
- 115406
- Inspections on file
- 20
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 26
Citation history
Health deficiencies cited at Wrightsville Manor Health And Rehab during CMS and state inspections, most recent first.
A resident with schizoaffective disorder, vascular dementia, and independent mobility, who was care-planned as an elopement risk, exited the building unsupervised through a side door that had been left unsecured while staff were attending a Christmas party. The door, previously held open with a latch to move a shower bed, was not secured after use, and the resident apparently followed someone out and left the premises. A community member later notified the facility after seeing the resident walking down the street, and staff confirmed the elopement and the circumstances under which the resident had been able to leave.
An LPN was observed administering medications to several residents without performing hand hygiene between each resident, handling medication carts, water cups, and door handles without cleaning hands. Although facility leadership expected hand hygiene between residents, the LPN only performed it before certain treatments, leading to a failure to prevent cross-contamination during medication administration.
A resident with severe cognitive impairment and an indwelling urinary catheter was not treated with dignity during meal service and catheter care. A CNA stood while feeding the resident instead of sitting, and the resident's catheter drainage bag was repeatedly left uncovered and visible in both private and common areas, contrary to facility expectations for privacy and dignity.
The facility did not provide required written transfer notices, including appeal rights and ombudsman contact information, to residents or their responsible parties when residents were transferred to the hospital. Bed hold notices were incomplete or missing, and notifications were not sent to the Ombudsman. Staff interviews confirmed that written notifications were not consistently provided, resulting in noncompliance with regulatory requirements.
A resident with an indwelling urinary catheter, severe cognitive impairment, and recent UTI hospitalization was observed multiple times with their catheter drainage bag and tubing lying on the floor, both in bed and in a chair. Staff confirmed this placement was inappropriate and not in line with infection control practices, and the facility's policy did not address proper catheter bag placement.
A resident who required dialysis did not receive safe and appropriate dialysis care and services as needed. The facility did not ensure that dialysis care was provided according to the resident's requirements.
Surveyors identified that the medication error rate in the facility was 5 percent or greater, indicating that medication administration was not performed with sufficient accuracy and exceeded regulatory standards.
A resident with diabetes experienced a hypoglycemic episode that was confirmed and treated by an LPN, but the incident was not documented in the medical record. Interviews with the resident, LPN, and ADON confirmed the event and the lack of documentation, despite facility expectations for such events to be recorded.
A resident with severe cognitive impairment was found standing over another resident with Alzheimer's Disease, leading to a sexual abuse investigation. Blood was found on the female resident's brief, and she was later treated at a hospital for vaginal tears. The facility's policy lacked a definition of sexual abuse, contributing to staff uncertainty. The male resident was arrested but returned to the facility due to mental capacity, and was later transferred to a behavioral health facility.
A resident was sexually abused by another resident, and the facility failed to conduct a thorough investigation. Staff observed the alleged perpetrator entering and leaving the victim's room, and the victim was later found with signs of sexual assault. The DON and Administrator did not take immediate action to prevent further harm, and the facility's inaction led to a situation of immediate jeopardy.
Resident Elopes Through Unsecured Side Door During Staff Party
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment free of accident hazards and to provide adequate supervision to prevent elopement for one resident identified as at risk. The facility had an elopement policy stating it would identify, prevent, detect, and respond promptly to resident elopement, and the resident’s care plan documented that he was at risk for elopement due to independent ambulation, paranoid schizophrenia, anxiety, and hallucinations/delusional thoughts. The care plan goals included that the resident would not leave the facility unsupervised and that staff would take appropriate steps to prevent and detect elopement, including use of electronic door locks, staff education, and staff control of door access. The resident had diagnoses including schizoaffective disorder, vascular dementia, psychotic disturbances with hallucinations and delusions due to a known physiological condition, muscle weakness, and dysphagia. A recent MDS showed he was cognitively intact with a BIMS score of 15, had disorganized thinking that did not fluctuate, and was independent with mobility and had no range-of-motion limitations. Progress notes documented that on the day of the incident, a community member called the facility reporting that he believed a facility resident was walking down the street. Facility staff went to the location, verified the resident’s identity, and found him unharmed, but he refused to get into the vehicle to return and stated, “ya’ll are trying to kill me,” demanding that police be called and agreeing to return only with an officer. Interviews and record review showed that the resident was able to exit the building without staff supervision during a staff Christmas party. Staff reported that the resident likely went out behind someone when a door was opened, and that the exit door on the 200 Hall had previously been equipped with a latch/hook used to hold it open for moving a shower bed. The DON and Administrator stated that at the time of the elopement, the side door used for the shower bed was not secured after a staff member brought the shower bed in, allowing the resident to leave the facility. The Administrator confirmed that this occurred while all staff were present at the Christmas party and stated that staff assigned to residents were expected to be accountable to them.
Failure to Perform Hand Hygiene During Medication Pass
Penalty
Summary
The facility failed to administer medications in a manner that prevented cross-contamination for seven of thirteen residents observed during a medication pass. An LPN was observed repeatedly preparing and administering medications to multiple residents without performing hand hygiene between residents. The LPN handled the medication cart, medication cards, water cups, and touched door handles and other surfaces both inside and outside the building, as well as objects in the residents' environments, without cleaning her hands between each interaction. In one instance, the LPN only performed hand hygiene before administering eye drops, which she considered a treatment, but not between other medication administrations. The LPN acknowledged touching surfaces and objects that could contribute to cross-contamination and confirmed that she did not perform hand hygiene between residents unless a treatment was involved. During interviews, the Assistant Director of Nursing stated that staff were expected to perform hand hygiene before starting the medication pass and between each resident, and that handwashing should be repeated if hands became soiled. However, the facility did not have a specific handwashing policy, relying instead on a skills check for staff. Documentation showed that the LPN had been assessed as competent in handwashing, with instructions to perform hand hygiene between each resident's medication pass. Despite this, the observed practice did not align with these expectations, resulting in a failure to prevent potential cross-contamination during medication administration.
Failure to Maintain Resident Dignity During Feeding and Catheter Care
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity during meal service and the care of an indwelling urinary catheter. The resident, who was admitted with diagnoses including pseudobulbar affect, generalized anxiety disorder, and abnormal weight loss, was noted to have severe cognitive impairment and was dependent on staff for most activities of daily living. During meal service, a CNA stood at the resident's bedside while feeding her, rather than sitting, which is considered a dignity concern. The CNA stated she was unaware that standing while feeding a resident was an issue related to dignity, and the Assistant Director of Nursing confirmed that staff had not been in-serviced on this expectation. Additionally, the resident's urinary catheter drainage bag was observed on multiple occasions to be uncovered and visible, both in the resident's room and in a common area, with urine visible in the bag. The drainage bag was also found lying on the floor under the resident's chair without a dignity cover. Staff interviews confirmed that the use of dignity covers for catheter bags was an expectation, but the cover was not in place at the time of observation. These actions and inactions resulted in a failure to maintain the resident's dignity during care and daily activities.
Failure to Provide Required Written Transfer Notices and Bed-Hold Information
Penalty
Summary
The facility failed to provide required written transfer notices, including information on appeal rights and ombudsman contact details, to residents and/or their responsible parties (RPs) when residents were transferred to the hospital. Additionally, the facility did not send copies of these notices to the Long Term Care Ombudsman for any of the five residents reviewed for hospitalizations. The facility's policy required that residents and their RPs be informed of transfer reasons, appeal rights, and bed-hold policies, but documentation showed these steps were not followed. Record reviews for multiple residents revealed that while verbal notifications were made to RPs regarding hospital transfers, there was no evidence of written notifications being provided. Bed hold notices, when present, were undated, unsigned, and did not specify the daily bed hold rate for private or semi-private rooms. In several cases, there was no documentation that the resident or RP received any written notice regarding the transfer or the facility's bed-hold policy at the time of transfer. Progress notes and other EMR documentation confirmed the absence of these required notifications. Interviews with facility staff, including the Administrator and Social Services Director, confirmed that written notifications were not consistently provided to RPs or sent to the Ombudsman. The Administrator acknowledged that while residents were sent with bed hold notices, RPs were not provided with this information, and the Social Services Director was unaware of the requirement to notify the Ombudsman for all hospital transfers. These actions and omissions resulted in a failure to comply with regulatory requirements for resident transfer notifications.
Improper Management of Urinary Catheter and Drainage Bag
Penalty
Summary
A deficiency was identified regarding the management of a urinary catheter and drainage bag for one resident with an indwelling urinary catheter. The facility's Foley Catheter Policy did not address the proper placement of urinary catheter drainage bags and tubing. The resident, who had diagnoses including pseudobulbar affect, generalized anxiety disorder, abnormal weight loss, and was severely cognitively impaired, was dependent on staff for most activities of daily living. The care plan for this resident included interventions to position the catheter bag and tubing below the level of the bladder and to check for kinks to ensure proper urine flow. The resident had a recent hospitalization for a urinary tract infection. During multiple observations, the resident's urinary catheter drainage bag and tubing were found lying on the floor, both while the resident was in bed and when seated in a geriatric chair in the common area. Staff interviews confirmed that the catheter bag and tubing should not be on the floor due to infection control concerns. Both a CNA and the ADON acknowledged that the observed placement of the catheter bag and tubing was inappropriate and not in accordance with infection control practices.
Failure to Provide Safe and Appropriate Dialysis Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate dialysis care and services for a resident who required such services. The facility failed to ensure that the necessary dialysis care was provided in accordance with the resident's needs. Specific details about the actions or omissions that led to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
A medication error rate of 5 percent or greater was identified during the survey. This indicates that the facility failed to ensure that the administration of medications was performed with an acceptable level of accuracy, resulting in a higher than permitted rate of medication errors among residents. The deficiency was based on direct findings by surveyors regarding the facility's medication administration practices, as evidenced by the calculated error rate exceeding the regulatory threshold.
Failure to Document Hypoglycemic Episode
Penalty
Summary
A deficiency occurred when the facility failed to document an episode of hypoglycemia for a resident with type 2 diabetes mellitus. The resident was admitted with orders for fingerstick blood sugar checks before meals and at bedtime, with instructions to notify the physician if levels were below 80 or above 400. On the day in question, the resident experienced symptoms of low blood sugar, which was confirmed by an LPN who measured a blood sugar level of 61. The LPN administered orange juice and sugar, and a subsequent check showed the blood sugar had risen to 91. Despite this event, there was no documentation of the incident in the resident's electronic medical record. Interviews with the resident, the LPN involved, and the Assistant Director of Nursing (ADON) confirmed that the hypoglycemic episode occurred and that it was not documented. The ADON and facility administration both stated that it was their expectation for such episodes to be documented according to current standards of practice. The lack of documentation was verified through review of the entire electronic medical record and direct staff interviews.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse, resulting in an incident involving two residents. One resident, who had severe cognitive impairment, was found standing over another resident, who was legally blind and had Alzheimer's Disease, in her room. Blood was noted on the resident's brief, and upon examination at the hospital, she was found to have vaginal tears and was given STI prophylaxis. The incident was witnessed by a nurse who saw the male resident standing over the female resident, and blood was later found on his pants. The facility's policy on abuse prevention did not include a definition of sexual abuse, which may have contributed to the staff's uncertainty about the nature of the incident. Interviews with staff revealed that the male resident had a history of inappropriate behavior, such as exposing himself, but was not considered to have sexually inappropriate behaviors towards other residents. The Director of Nursing and other staff expressed doubt about the male resident's capability to perform a sexual act, suggesting that any assault would have been with his hands. The incident was reported to the police, and the male resident was arrested but returned to the facility due to his mental capacity. The facility placed him on 15-minute checks and moved him to a locked unit until he could be transferred to a behavioral health facility. The female resident was transferred to the hospital for examination and returned to the facility after the incident. The facility's response to the incident included interviews with staff and residents, but the initial failure to prevent the abuse and the lack of a clear policy definition of sexual abuse were significant factors in the deficiency.
Removal Plan
- Abuse Prevention education is ongoing with staff by Administrator, Staff Development Coordinator or Director of Nursing. All employees have received education. Prevention education is provided upon hire by HR director and periodically throughout employment by regulation guidelines. No new staff will be able to work without receiving the education.
- Social Service Director interviewed all residents with BIMS 13 or above, asking if anyone injured them, came in their room, or sexually abused them. For residents unable to answer, skin assessments are performed on all residents weekly by treatment nurse. Weekly skin assessments were completed with no injuries found per treatment nurse.
- A camera was placed in R1's room and the monitor placed at nurses' station, with family's permission for closer observation and residents' inability to communicate related to potential abusive encounters.
- R1 was assessed upon return by nurse S.T. with no new findings/bleeding observed.
- Social Service Director began interviewing all residents, asking them if a person has been in their room touching or hurting them.
- Medical Director was notified of 3 Ij's.
- Medical Director reviewed the abuse policy and made no changes.
- QA reviewed state report of incident with R1 and R2. R2 did not return to facility, resolving the situation, as R2 was admitted to a behavioral health facility.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility administration failed to protect a resident from sexual abuse by another resident and did not conduct a thorough investigation following the incident. On the night of the incident, a resident was observed by staff entering and leaving the room of another resident. The staff later found the resident in bed with signs of sexual assault, including blood in the vaginal area. The resident was subsequently transferred to the emergency room for evaluation, where a sexual assault exam confirmed injuries consistent with rape. The Director of Nursing (DON) and the Administrator were informed of the incident but did not take immediate and appropriate actions to prevent further harm. The DON expressed uncertainty about whether the incident constituted rape and suggested that the alleged perpetrator was not capable of such an act. Despite the severity of the situation, the facility did not implement one-on-one supervision for the alleged perpetrator, who was only placed on 15-minute checks until he could be transferred to a behavioral facility. The facility's failure to maintain a safe environment and adequately investigate the incident was identified as noncompliance with federal requirements, posing a likelihood of serious harm to residents. The administration's inaction and lack of oversight contributed to the immediate jeopardy situation, which was recognized by surveyors and communicated to the facility's leadership.
Removal Plan
- Director of operation reviewed Abuse Neglect and Exploitation misappropriation program in-serviced Administrator and DON.
- Administrator and DON signed job descriptions on hire date. Director of operations reviewed job descriptions.
- The facility held Ad Hoc QAPI meeting to review the Immediate Jeopardy findings Medical Director was over the phone. Administrator, DON, Adon, Treatment nurse, MDS, Social Service, Activity, Maintenance, Housekeeping, HR, Admissions, Dietary, IFP, CNA, Unit Manager.
- The allegations of sexual abuse of R1 have been reported and investigated by administrator and DON and the necessary corrective actions were taken to assure they do not happen again, R2 was removed from facility and is discharged. R1 has a room monitor with camera and it stays on at the nurse's station to allow staff to see R1.
- Abuse prevention is given by HR on hire. No new employee will be able to work without receiving education.
- Social Service director has called an emergency Abuse and prevention and resident rights meeting. The meeting was held with resident counsel.
- Social Service director completed interview with all residents asking them has a person been in their room touching or hurting them, all that could answer stated no. Residents that could not answer were reviewed on skin assessments for injury, tears, bruises.
- Skin assessments were started on all residents weekly by treatment nurse. Each hall is on a different day, treatment nurse observes for any skin tears, bruises, sores, etc. Skin assessments were completed.
- Confirmation via signed document stating Abuse, Neglect, exploitation misappropriation prevention program was reviewed and in-serviced by the Director of Operations. Signatures by the Director of Operations, Administrator, and the Director of Nursing.
- Review of signed statement indicating the Director of Operations reviewed Administrator and DON job descriptions. Copy of job descriptions attached and signatures by the Director of Operations, Administrator, and Director of Nursing.
- Review of document titled Quality Assurance/Performance Improvement Meeting Format indicated signatures for Administrator, DON, ADON, Treatment nurse, MDS, Social Service, Activity, Maintenance, Housekeeping, HR, Admissions, Dietary, IFP, and Unit Manager.
- Review of the Census of the electronic medical record (EMR) R2 discharged from the facility. Review of Progress Notes indicated that R2 was picked up by transportation and taken to a behavior health center.
- Observation a monitor was observed at the nursing station showing R1 in bed asleep.
- Review of signed document signed by Administrator and Human Resources (HR) indicating HR will be responsible for giving abuse prevention policy to new hires.
- Interview with HR, who confirmed there have been no new hires. She reported that she is responsible for reviewing the abuse policy with new hires and will get them to sign off on this during orientation.
- Review of document titled Resident Council Meeting indicated topics discussed of Resident Rights, Abuse Prevention, and Reporting Abuse. Policy reviewed Abuse Prohibition Policy and Procedures and Resident's Federal and State Rights.
- Interview with the Administrator who confirmed that an Emergency Resident Council meeting was held to discuss abuse prevention and resident's rights.
- Interviews with R3 and with R11 who both confirmed attending the resident council meeting.
- Review of document which listed total residents and their response (No or no response) to a question about anyone coming into their room unwelcomed making sexual advances or inappropriate touch. None of the residents reported yes to the question. This was completed by the Social Services Director.
- Review of skin assessment documentation confirmed skin assessments were completed for all residents.
- Review of the skin assessment documents indicated skin assessments completed weekly. This was also confirmed through a calendar that indicated the dates that skin assessments were completed for each hall.
Latest citations in Georgia
Surveyors found that clean linens and personal clothing were stored and staged in close proximity to the dirty laundry area, with an open door between the clean and soiled sides and all washer and dryer doors open. Clean resident clothes, unlabeled garments, and bagged items were placed next to dryers and directly in front of the dirty linen room, and dirty barrels had to be pushed past racks of clean clothing to reach the washers, contrary to facility policies requiring separation of clean and soiled linens. Environmental staff believed keeping doors open and covering dirty barrels reduced infection spread, while the Environmental Services Director, IP nurse, and Administrator acknowledged that the dirty room door should be closed, linens should not be on dirty barrels, and clean resident clothing should not be stored in that location.
A resident with a suprapubic catheter, colostomy, sacral wound, and dependence on staff for bathing and hygiene was care planned for Enhanced Barrier Precautions (EBP), including use of PPE during high-contact care. During observed catheter care and a bed bath, a CNA wore only gloves and did not don a gown, despite EBP signage and a star posted on the door and PPE supplies available outside the room. In interviews, the CNA admitted forgetting to wear a gown and not recognizing additional required actions, while the IP nurse and DON confirmed that staff had been educated that gowns and gloves are required for high-contact care involving indwelling devices and wounds under the facility’s EBP policy.
A resident with multiple neurologic and psychiatric diagnoses, intact cognition, and unilateral functional limitations was found with an open box of lubricant eye drops stored at the bedside without any documented assessment for self-administration or prescriber’s order for self-administration or bedside storage, contrary to facility policy. Observations on multiple days confirmed the eye drops remained at the bedside, while staff interviews showed that CNAs and the IP recognized that residents were generally not to self-administer medications and that bedside medications required assessment and orders. The Administrator confirmed that the resident should not have had eye drops in the room and that residents with bedside medications are typically assessed for self-administration, and staff acknowledged that unsecured eye drops at the bedside could be accessed or ingested by other residents and cause harm.
The facility failed to maintain a safe, clean environment when multiple ceiling tiles throughout the building, including above a resident’s bed, near the nurses’ station, in a glass day room above a resident’s chair, and in a main hall, were observed with brown circular stains, bulging, and a white moldy substance. The Maintenance Director confirmed the stained and bulging tiles, acknowledged the risk that tiles above a resident’s bed could fall, and attributed the condition to rain-related roof leaks. The Administrator also confirmed that roof leaks and recent rainfall caused the brownish stains despite her reported daily rounds.
A resident with severe cognitive impairment, on hospice and fully dependent for ADLs, was sexually abused when another cognitively impaired male resident with a long-standing history of sexually inappropriate behavior toward female residents entered her room and placed his hand inside her pants. The abusing resident had multiple dementia and psychiatric diagnoses, was care planned for sexually inappropriate behaviors with prior documented incidents, and was on psychotropic medication for OCD-related sexual obsession. Despite these known risks and existing care plan interventions, he was able to access the female resident’s room and make inappropriate physical contact, and the facility’s investigation substantiated the abuse.
Surveyors found that the facility failed to develop and implement complete, person-centered care plans for two residents. One resident was receiving an antipsychotic (Haloperidol) for schizophrenia with associated behavior and side-effect monitoring orders, but there was no corresponding care plan addressing antipsychotic use or its indication. Another resident had an indwelling Foley catheter for neurogenic bladder related to prostate cancer, with goals to prevent catheter-related trauma; however, the care plan omitted key interventions such as balloon volume parameters and use of a leg strap or securement device, despite physician orders requiring a leg strap and observations showing the catheter positioned under the leg without securement. An MDS coordinator and the administrator acknowledged that required interventions and standard catheter care components were missing from the care plans.
A resident with a history of resistiveness to care and noncompliance with the non‑smoking policy had a comprehensive care plan that was not updated to reflect multiple interventions implemented in response to repeated smoking and vaping violations. Although the care plan noted the need for supervision while smoking and review of the smoking policy, it did not include measures such as daily room searches for smoking materials, added smoke detection in the room, relocation closer to the nurses’ station, q2h visual rounds for smoke, post‑outing nursing checks, initiation of a PAR process for vaping, or issuance of a discharge notice. Facility forms showed inconsistent documentation of daily room searches and incomplete IDT documentation on the PAR tracking, despite multiple documented episodes of policy violations and removal of vaping devices.
A cognitively intact but physically impaired resident with a history of noncompliance with the facility’s non‑smoking policy repeatedly smoked and vaped in his room while keeping multiple vape devices and other items at bedside. The facility’s Smoking Policy required that non‑compliant smokers have daily documented searches and be prohibited from keeping smoking materials in their rooms, yet monitoring forms showed many days without documented searches, Patient at Risk tracking was incomplete, and staff acknowledged that daily room checks and frequent rounds were not consistently performed. Multiple staff, including a CNA, social worker, Infection Preventionist, MDS coordinator, Activities Director, and the Administrator, reported ongoing violations and repeated discovery of vape devices in the resident’s room, including during surveyor observations, demonstrating that the environment was not maintained free from accident hazards and that required supervision and monitoring were not reliably implemented.
Surveyors found that a treatment cart containing topical medications was left unlocked and unattended in a hall across from a resident’s room after wound care was completed by an LPN. The facility’s policy requires that medication carts and supplies be locked or attended and accessible only to licensed or otherwise authorized staff. During interviews, the LPN confirmed the cart had been left unlocked and unattended, the IP LPN confirmed the LPN’s report that the cart was left unlocked, and the Administrator stated that all medications, including topical medications, were expected to be locked when not in sight of authorized staff.
The facility failed to implement its infection prevention and control program by not operationalizing a documented Legionella water management plan despite having a written policy, and by not fully implementing Enhanced Barrier Precautions (EBP) for residents with indwelling devices and other risks. A resident with an indwelling urinary catheter had no EBP care plan or orders, no EBP signage, and staff providing catheter care wore only gloves without gowns, while multiple staff members reported not knowing what EBP was or misidentified who should be on EBP. Another resident receiving tube feeding had care initiated by an LPN who wore gloves but no gown and repeatedly touched her hair with the same gloved hands before handling the feeding tube and equipment, later acknowledging she should have changed gloves and was unaware of EBP requirements, even though other clinical staff stated gowns and gloves should be used for feeding tube care. A resident on isolation for C. diff had a door sign indicating isolation but no instructions for visitors on required PPE or to seek staff guidance, and the IP confirmed there was no system to direct visitors about precautions, contributing to the overall infection control deficiency.
Failure to Maintain Separation of Clean and Soiled Laundry
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to separation of clean and soiled linens. Facility policies titled “Infection Prevention and Control Program” and “Handling Soiled Linens” required that clean linen always be separated from soiled linen. During an observation of the laundry area, all washer and dryer doors were open in the clean linen area. Clean linens, including sheets, towels, blankets, and washcloths, were folded on a table to the left of the washer and dryer room. On the right side of the room, next to the dryers and directly in front of the open door to the dirty laundry room, there were residents’ clean clothes on a rack, piles of folded clean clothes to be hung, a rack of unlabeled clothes, and a bag of unlabeled clothes. Dirty laundry barrels had to be pushed past the clean clothing on the racks to reach the washers, placing soiled items in close proximity to clean items despite policy requirements for separation. Environmental staff working in the laundry stated they believed they were reducing the spread of infection by keeping all doors open, covering dirty barrels, and circulating air, and they explained that the uncovered rack and bagged clothes near the dirty area were no-name clothes sometimes distributed to residents in need. They also stated that the rack of clean personal resident clothing parked in front of the open dirty linen room door was awaiting distribution by a staff member who worked only at night. The Environmental Services Director reported that the door to the dirty side of the laundry should always be closed and that no linen should be on top of dirty barrels. The Infection Preventionist nurse, when shown pictures and concerns about cross-contamination, confirmed there was a problem in the laundry but stated she had not been aware of it previously. The Administrator stated that residents’ clothes should not be stored where they were observed and should be handed out immediately once clean, and that she expected the laundry to be organized to prevent cross-contamination between dirty and clean clothes.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff followed its Enhanced Barrier Precautions (EBP) policy for the use of personal protective equipment (PPE) during high-contact care. The facility’s EBP policy, updated February 2025, requires gowns and gloves for residents with wounds and/or indwelling medical devices, including urinary catheters and ostomies, when staff perform high-contact activities such as bathing, dressing, toileting, hygiene, and catheter care. The policy also directs that gowns and gloves be made available near or outside the resident’s room and that EBP be implemented for residents with indwelling devices or wounds, even if they are not known to be infected or colonized with a multidrug-resistant organism. The resident involved had a suprapubic catheter, colostomy, sacral wound, and neurogenic bladder and bowel, and was care planned for EBP implementation during catheter and skin care. The resident was cognitively intact but dependent on staff for bathing, dressing, toileting, hygiene, bed mobility, and transfers, and used an indwelling catheter and ostomy. During an observation, a CNA provided suprapubic catheter care and a bed bath to this resident while only wearing gloves, despite EBP signage and a star posted on the door and PPE supplies available outside the room. The CNA did not don a gown and was unable to identify any additional actions needed before care until prompted about the EBP signage, at which point he acknowledged he should have worn a gown but forgot. In a subsequent interview, the IP nurse and DON confirmed that staff had been educated that gowns are required during high-contact care for residents with catheters, colostomies, and other devices, and that the posted signage and star were intended to alert staff to the need for enhanced PPE use.
Failure to Assess and Obtain Orders for Self-Administration and Bedside Medication Storage
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policies for self-administration of medications and bedside medication storage for one resident. The facility’s policies require that residents who wish to self-administer medications must be assessed by the interdisciplinary team for cognitive, physical, and visual ability, and that a prescriber’s order for self-administration and bedside storage must be present in the medical record and reflected on the MAR and medication label. For the resident in question, who had diagnoses including cerebral infarction, major depressive disorder with psychotic symptoms, PTSD, hemiplegia and hemiparesis, speech and language deficits, and cerebral atherosclerosis, the EHR showed no assessment for self-administration and no physician order for self-administration or bedside storage, despite active ophthalmic medication orders. The resident’s MDS documented intact cognition with a BIMS score of 15, use of corrective lenses, and functional limitations in range of motion on one side of both upper and lower extremities. Surveyor observations on two consecutive days found an open box of lubricant eye drops on the resident’s bedside table. Staff interviews revealed inconsistent understanding and enforcement of the facility’s policies. A CNA stated that residents did not self-administer medications and that only nurses administered them, but also reported that when she previously reported the eye drops, she was told the resident could have them because he was independent. The Infection Preventionist acknowledged the resident had an order for eye drops and believed he obtained them from the VA, and stated he should not have the lubricant eye drops because they were a hazard for other people. The Administrator confirmed that typically a resident with medications at the bedside should be assessed for self-administration and stated the resident should not have eye drops in his room. The report notes that unsecured medications at the bedside had the potential to cause adverse reactions if accessed or ingested by other residents.
Failure to Maintain Safe and Clean Ceiling Surfaces Throughout Facility
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable homelike environment as required by its Maintenance Service policy, which assigns the Maintenance Department responsibility for keeping the building in good repair and free from hazards. Surveyors observed multiple stained and damaged ceiling tiles in several areas of the facility, including near the nurses' station, in a resident bedroom (room [ROOM NUMBER]A), in the glass day room, and in the middle of the east hall. On several occasions, ceiling tiles near the nurses' station were noted to have tannish-brown circular stains of varying sizes, and at one point a white, moldy substance was observed on a ceiling tile in that same area. In room [ROOM NUMBER]A, surveyors observed brown rings roughly 16 inches in diameter on ceiling tiles located directly above a resident’s bed, with the Maintenance Director later confirming that these tiles were stained, bulging, and at risk of falling on the resident. Additional observations in the glass day room identified two stained ceiling tiles above a resident’s chair, each with brown circular stains approximately three inches in diameter. In the east hall, a ceiling tile with a brown circular stain approximately 10 inches in diameter was also documented. The Maintenance Director and the Administrator both acknowledged that the stains and damage were related to roof leaks associated with recent rainfall, and the Administrator confirmed awareness of roof leaks that had previously been repaired and that the brownish stains were due to recent rain.
Failure to Prevent Sexual Abuse of a Cognitively Impaired Resident by Another Resident
Penalty
Summary
The facility failed to protect a dependent, cognitively impaired resident (R113) from sexual abuse by another resident (R12). R113 had severe cognitive impairment with a BIMS score of 5, was on hospice care, and was fully dependent for toileting, bathing, dressing, footwear, and personal hygiene. On the day of the incident, a CNA observed R12 in R113’s room with his right hand inside R113’s pants while she was seated in a geriatric chair. Staff witness statements and nursing progress notes documented that R12 was found in R113’s room with his hand in her pants, and the facility’s investigation substantiated that R12 touched R113 inappropriately. R12 also had severe cognitive impairment with a BIMS score of 4 and multiple psychiatric and dementia-related diagnoses, including vascular dementia with mood disturbance, Alzheimer’s disease, major depressive disorder, obsessive-compulsive personality disorder, unspecified psychosis, and unspecified mood affective disorder. He required extensive physical assistance, used a manual wheelchair, and was fully dependent for toileting, bathing, lower body dressing, and footwear. R12’s care plan, in place since 2017, identified him as having sexually verbally and physically inappropriate behavior, including documented prior incidents in which he inappropriately touched or attempted to touch female residents. His care plan included interventions such as discussing his behavior when reasonable, explaining that it was inappropriate, intervening to protect others, diverting his attention, and removing him from situations as needed, as well as monitoring and recording occurrences of target behaviors such as sexual aggression toward others. Despite this known history of sexually inappropriate behavior toward female residents and the presence of care plan interventions, R12 was able to enter R113’s room and place his hand inside her pants. The Administrator confirmed that the CNA reported finding R12 in R113’s room with his hand in her pants while R113 was in her wheelchair, and that the facility’s investigation substantiated the abuse allegation. The facility’s abuse policy stated that it would not condone resident abuse by anyone, including other residents, and defined sexual abuse to include sexual harassment, sexual coercion, or sexual assault. The occurrence of this incident demonstrated that the facility did not effectively prevent sexual abuse of R113 by another resident, despite R12’s documented behavioral history and existing care plan.
Failure to Develop and Implement Complete Care Plans for Antipsychotic Use and Foley Catheter Management
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for identified resident needs, as required by its Comprehensive Care Plan policy. The policy states that care plans must address all needs identified in the comprehensive assessment, including medical, nursing, mental, and psychosocial needs, and must be developed within seven days after completion of the comprehensive MDS assessment. It also requires that all triggered Care Area Assessments (CAAs) and other factors identified by the IDT or resident preferences be incorporated into the plan of care. For one resident, R44, the clinical record showed physician orders for Haloperidol 10 mg by mouth twice daily for schizophrenia, along with orders for behavior monitoring and psychiatric medication side effect monitoring. Despite these orders, the resident’s care plan dated 03/11/2026 did not include any care plan addressing antipsychotic medication use or its indication. The MDS Coordinator stated that all residents receiving antipsychotic treatment should have a comprehensive care plan in place beginning with the date the medication was originally ordered, and upon review of the record confirmed that such a care plan was not present for this resident at the time of the survey. For another resident, R3, the care plan dated 03/13/2026 identified a problem of an indwelling catheter secondary to neurogenic bladder related to prostate cancer, with goals including remaining free from catheter-related trauma. The listed interventions included positioning the catheter bag and tubing below bladder level, monitoring and documenting intake and output per policy, and monitoring for pain, discomfort, and signs and symptoms of UTI. However, the care plan did not address the amount of water in the catheter balloon, use of a leg strap or securement device, or other securement measures. Physician orders specified checking a leg strap every shift and documented that the resident was admitted with an 18F catheter attached to a bedside drainage bag, but observations showed the Foley catheter positioned under the resident’s leg without a leg strap or securement device on two occasions, and a CNA reported being unaware that a leg strap was required. The MDS Coordinator confirmed that these ordered interventions were missing from the care plan.
Failure to Revise Care Plan for Ongoing Smoking Policy Noncompliance
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive care plan to reflect current interventions implemented in response to ongoing noncompliance with the facility’s non‑smoking policy. The facility’s policy requires that the comprehensive care plan be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment, and that it include measurable objectives, timeframes, and alternative interventions as needed, with qualified staff notified when changes are made. The resident’s care plan included a focus on resistiveness to care and noncompliance with smoking, noting that the resident continued to go outside beyond facility property to smoke, and an intervention to review the smoking policy with the resident. Another care plan focus identified the resident as a smoker requiring supervision while smoking, with interventions stating the resident required supervision while smoking and that the charge nurse should be notified if a smoking policy violation was suspected. Despite repeated and ongoing noncompliance with the non‑smoking policy, the care plan was not revised to include additional interventions that were actually implemented. These unreflected interventions included daily room searches for smoking paraphernalia, placement of a smoke detector in the resident’s room, relocation of the resident’s room closer to the nursing station, every‑two‑hour visual rounds to check for smoke, nursing checks upon return from outings, initiation of a Patient at Risk (PAR) process for vaping noncompliance, and issuance of a 30‑day discharge notice for repeated violations of the non‑smoking policy. Documentation on the Smoking Materials Monitoring Form showed initials on selected days only, indicating daily room searches were not consistently completed and documented for the entire month. The PAR Smoking Tracking form documented multiple observations of vaping in the room, repeated room checks, removal of vapor devices, and the resident’s refusal to comply with facility policies, with later weeks lacking IDT signatures and documentation, while the PAR Grid showed multiple prior entries for violating the non‑smoking policy.
Failure to Control Smoking and Vaping Hazards for a Noncompliant Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision for a resident with a known history of noncompliance with the facility’s non‑smoking policy. The facility’s Smoking Policy requires that residents not be allowed to keep cigarettes, cigars, pipes, matches, or lighters in their possession or rooms, and that non‑compliant smokers receive daily searches with documentation, while compliant smokers receive weekly searches. The policy also requires incident reports and review in a “Patients at Risk” process whenever smoking materials are found. Despite these written procedures, the resident’s Smoking Materials Monitoring Form for April showed multiple days without documented searches, indicating that required daily room searches were not consistently completed or recorded. The resident at issue was cognitively intact, with a BIMS score of 15, and had significant physical impairments including hemiplegia and hemiparesis on the left side, use of a manual wheelchair, and other neurologic and psychiatric diagnoses such as cerebral aneurysm, cerebral infarction, major depressive disorder with psychotic symptoms, PTSD, and speech and language deficits. The care plan identified the resident as resistive to care and noncompliant with smoking, noting that he continued to go outside beyond facility property to smoke, and also identified him as a smoker requiring supervision while smoking. Progress notes and Patient at Risk documentation showed a pattern of repeated violations of the non‑smoking policy, including multiple instances of vaping and smoking in his room, with staff repeatedly finding vape devices and other smoking paraphernalia in his possession and in his room. Throughout the period reviewed, staff observations and interviews confirmed ongoing noncompliance with the smoking policy and inconsistent implementation of the facility’s own interventions. Staff documented several occasions when the resident was observed vaping or smoking in his room, including in the presence of a state surveyor, and room searches revealed multiple vape devices hidden under the sheets. Staff interviews indicated that daily room checks were not always performed due to competing demands, that logs of every‑two‑hour rounds were not maintained, and that there was confusion or inconsistency regarding whether the resident could keep items such as air freshener at bedside. The social worker, Infection Preventionist, MDS coordinator, Activities Director, CNA, and Administrator all acknowledged that the resident’s room had to be searched for cigarettes and vaping paraphernalia and that prohibited items were repeatedly found, while documentation showed gaps in the required daily searches and incomplete follow‑through on the Patient at Risk tracking process. These actions and inactions resulted in the environment not being kept free from accident hazards as required by the facility’s policy and regulatory standards. The deficiency is further supported by the facility’s own records showing repeated entries on the Patient at Risk grid for violations of the non‑smoking policy over an extended period, as well as narrative notes describing the resident’s statements that he would continue to vape in his room and would simply obtain new devices if they were confiscated. Despite the known pattern of behavior and the facility’s policy requiring close supervision, daily searches, and thorough documentation for non‑compliant smokers, the monitoring forms and staff interviews demonstrate that these measures were not consistently carried out. The presence of multiple vape devices and cans of air freshener at the bedside during surveyor observations, along with staff acknowledgment that room checks were missed and that logs of frequent rounds were not kept, illustrate the facility’s failure to effectively implement its own safety procedures to prevent accident hazards related to smoking and vaping in the resident’s room.
Unlocked and Unattended Treatment Cart with Topical Medications
Penalty
Summary
Surveyors identified a deficiency related to medication storage when a treatment cart containing topical medications was left unlocked and unattended in a hall. The facility’s policy titled “Medication Storage in the Facility,” effective 10/01/2025, states that the medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff lawfully authorized to administer medications, and that medication rooms, carts, and supplies are to be locked or attended by authorized personnel. During an observation on 04/29/2026 at 9:35 AM, after wound care was provided to resident R3 by the wound care LPN, the treatment cart was observed left in the [NAME] hall across from R3’s room, unlocked and unattended for 30 minutes. In an interview, the wound care LPN confirmed that the treatment cart had been left unlocked and unattended. The Infection Preventionist LPN later confirmed that the wound care nurse told her the cart was left unlocked, and the Administrator stated that her expectation was that all medications, including topical medications, be locked when not in sight of a licensed nurse or authorized person. This deficient practice occurred in a facility with a census of 94 residents and involved the failure to follow the facility’s own policy requiring that medication carts be locked or attended by authorized personnel, resulting in unsecured access to topical medications on the treatment cart.
Failure to Implement Legionella Water Management and Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to provide and implement an infection prevention and control program, including a documented water management plan for Legionella and other waterborne pathogens, and a fully implemented Enhanced Barrier Precautions (EBP) program. The Administrator stated there was no Legionella water program in place, and the Maintenance Supervisor reported he was unaware of the requirement for such a program. This was despite the existence of a written Legionella Water Management Program policy, revised in September 2022, which described the need for an interdisciplinary water management team, detailed water system diagrams, identification of risk areas and situations for Legionella growth, control measures, monitoring systems, and annual review. Interviews confirmed that the expectation was that the facility would be conducting this water program, but it was not being done. The facility also failed to implement EBP for residents with indwelling medical devices and other risk factors, as required by its own policy. One resident with Alzheimer’s disease, urinary obstruction, and emphysema had an indwelling urinary catheter documented in the care plan and physician orders, but the care plan did not address EBP related to the catheter, and there was no order for EBP in the record. During catheter-related care, a CNA wore gloves but did not wear a gown, and there was no EBP signage or PPE setup at the room. Multiple staff members, including CNAs and a housekeeper who regularly worked on the resident’s hallway, reported they did not know what EBP was or incorrectly associated EBP only with residents on Transmission-Based Precautions. The DON acknowledged that an attempt to roll out EBP months earlier had not been completed, and that expected signage and PPE caddies for EBP were not fully in place. Additional infection control lapses were observed during tube feeding care and contact isolation. A resident receiving continuous tube feeding had a care plan and physician’s order for enteral nutrition, and an LPN initiated the feeding while wearing gloves but no gown. During the procedure, the LPN repeatedly touched her hair with the same gloved hands and then handled the feeding tube, pump, and syringe used to inject air and check residuals, only removing gloves and using hand sanitizer at the end. The LPN later acknowledged she should have changed gloves after touching her hair and stated she did not know what EBP was or that a gown was required for feeding tube care, while another LPN and the IP stated that EBP with gown and gloves should be used for feeding tube care and that staff should not touch their hair during care without changing gloves and performing hand hygiene. For a resident with a positive urine culture and a subsequent positive C. difficile culture who was on isolation, the door sign indicated isolation but did not provide instructions for visitors on required precautions or direct them to staff for guidance. The IP confirmed there was no system to direct visitors about PPE use for residents on contact isolation and acknowledged that visitors would not know to wear PPE if it was simply present in or on the door of the room. Overall, the survey findings show that the facility did not operationalize its written Legionella water management policy and did not consistently apply its EBP policy for residents with indwelling devices or wounds. Staff interviews and observations demonstrated a lack of knowledge and implementation of EBP, incomplete use of PPE during high-contact care activities such as catheter care and tube feeding, and unclear isolation signage that did not instruct visitors on appropriate precautions. These combined inactions and omissions in policy implementation, staff education, and practice led to the cited infection prevention and control deficiency.
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