Cambridge Post Acute Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Snellville, Georgia.
- Location
- 2020 Mcgee Road, Snellville, Georgia 30078
- CMS Provider Number
- 115771
- Inspections on file
- 19
- Latest survey
- February 6, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Cambridge Post Acute Care Center during CMS and state inspections, most recent first.
A resident with Alzheimer's disease and severe cognitive impairment, who was care planned to have her dignity and autonomy maintained, was self-propelling in a wheelchair and expressing the need to use the bathroom when a CNA stopped her and attempted to redirect her away from the hall she chose. When the resident insisted on going in her chosen direction and became upset, the CNA backed her wheelchair against a wall across from the nurses' station and locked the wheels to prevent further movement. The DON acknowledged that restricting a resident’s movement is against residents’ rights, and the Administrator stated that residents have the right to wander in the building, while also noting that residents are kept lined up near the nurses’ station for supervision, despite a facility policy requiring residents be treated with dignity and respect and that their input be honored.
A resident with a PICC line did not receive care according to facility policy and physician orders, including missed and improperly performed dressing changes, lack of chest x-ray confirmation after line insertion, and use of the line without placement verification. Staff interviews and observations revealed inconsistent practices, breaks in sterile technique, and incomplete adherence to enhanced barrier precautions.
A resident receiving IV antibiotics via a PICC line for infection and sepsis experienced multiple missed doses of prescribed medications when the PICC line was not usable. Nursing staff did not notify the physician or obtain alternative orders as required by facility policy, resulting in significant medication errors.
Staff did not consistently follow Enhanced Barrier Precautions and hand hygiene protocols during wound care for two residents with significant wounds and cognitive impairment. An LPN failed to use barriers for supplies, did not sanitize shared wound care items, and neglected to wear gowns or change gloves appropriately during high-contact care, despite posted precautions and facility policy. Staff interviews confirmed knowledge of protocols but acknowledged lapses in practice.
The facility failed to ensure proper labeling and storage of residents' basins, urinals, and bedpans in 11 shared rooms, as per their policy. Observations revealed these items were often unlabeled, unbagged, or placed on the floor, posing a risk of cross-contamination. The ICP confirmed that CNAs were responsible for proper labeling and storage, but this was not consistently done.
Three residents were found with unauthorized and unsecured medications at their bedside, posing a risk of medication errors and unauthorized access. One resident with moderate cognitive impairment had over-the-counter medication provided by her son, another had a pill he was unsure about, and a third had eye drops brought by family. None had been assessed or approved for self-administration, contrary to facility policy.
The facility failed to create comprehensive care plans for two residents, one with MRSA and another dependent on oxygen therapy. Despite documented diagnoses and physician orders, the care plans did not address these critical needs. Interviews with staff confirmed these oversights.
The facility failed to administer oxygen therapy according to physician orders and maintain clean oxygen concentrator filters for several residents. A resident received oxygen at a higher rate than prescribed, and observations revealed dirty filters on concentrators for three residents. The DON and LPNs confirmed the discrepancies and the responsibility of Sunday night shift nurses for equipment maintenance.
A facility failed to maintain a medication error rate below five percent, resulting in a 7.69 percent error rate for a resident with type 2 diabetes and IBS. An LPN administered an incorrect dosage of Linzess and failed to prime an insulin pen before use. The DON emphasized the importance of following medication administration protocols.
The facility failed to provide written information about its bed-hold policy to residents or their representatives during hospital transfers. This deficiency was identified for three residents, who did not receive the required documentation, leading to confusion and distress among families. Interviews with staff confirmed the lack of communication regarding the bed-hold policy.
The facility failed to implement its Antibiotic Stewardship program effectively, as two residents were prescribed antibiotics without using the McGreer Criteria to assess clinical indications. The Infection Control Preventionist admitted to not conducting infection surveillance due to a lack of training, resulting in inadequate monitoring and documentation of antibiotic use.
The facility's Infection Control Preventionist (ICP) failed to adequately manage the Infection Control and Prevention (IPCP) program, as required by the facility's policy. Despite completing the CDC Nursing Home Infection Preventionist Training Course, the ICP did not update her training since November 2022 and failed to implement necessary infection control measures, including an antibiotic stewardship program. This deficiency placed the facility's 136 residents at risk for infection transmission. The Administrator was aware of some issues but not the full extent.
The facility failed to maintain a safe and sanitary environment, with peeling wallpaper and water-stained ceiling tiles in a resident's room, and an unclean porch area with cat hair and urine odor. Residents expressed discomfort due to these conditions, and the Environmental Director acknowledged the need for regular cleaning.
The facility failed to develop person-centered care plans for residents with communication needs. A resident with a cochlear implant and moderate hearing difficulty lacked a care plan for hearing loss. Another resident with severe cognitive impairment and a preferred language of Korean had no care plan for her language barrier. A resident with moderate cognitive impairment and a preferred language of Spanish also lacked a care plan for his language barrier, and there were no communication boards available. A resident who preferred Vietnamese and had no cognitive impairment was unable to consistently communicate in English and did not have a care plan addressing this issue.
The facility failed to ensure that Certified Medication Technicians (CMTs) were competent in insulin administration, as three out of five CMTs lacked documented skills and knowledge. CMT MM had no completed competency checklist, CMT LL was unaware of the need for insulin dosage verification by a licensed nurse, and CMT FF was uncertain about her competencies. The Staff Development Coordinator confirmed the absence of specific competency documentation for insulin administration.
The facility failed to administer medications as ordered for two residents, leading to missed doses of critical medications. One resident missed doses of an inhaler and Atorvastatin, while another missed doses of Pregabalin. Interviews revealed systemic issues, including challenges with insurance authorizations and delays in medication delivery, contributing to these failures.
A LTC facility failed to administer insulin as ordered for three residents, leading to significant medication errors. Discrepancies were found in blood sugar documentation and insulin administration, with multiple instances of insulin not being given according to sliding scale orders. Interviews revealed a lack of awareness and oversight by the facility's staff.
The facility failed to implement enhanced barrier precautions (EBP) and transmission-based precautions (TBP) for two residents, leading to potential cross-contamination. A resident with pressure sores did not receive proper PPE use during wound care, and signage was not visible. Another resident with a PICC line and MRSA had delayed TBP implementation, with staff unaware of the need for precautions. The Infection Control Preventionist was absent, and the Unit Manager did not ensure proper signage and PPE availability.
A facility failed to update a resident's care plan to include interventions for an unstageable sacral pressure ulcer. The resident, with a history of cerebral vascular accident and other conditions, had a care plan that addressed other wounds but not the sacral ulcer. The MDS Coordinator confirmed the oversight, which placed the resident at risk for unmet care needs.
Expired insulin vials were found on two medication carts, posing a risk to residents. An LPN confirmed that a Lantus insulin vial was used past its expiration, and another vial of Novolog lacked an open date. The pharmacist and DON acknowledged ongoing issues with expired medications, emphasizing the need for immediate removal from carts.
A resident with Alzheimer's disease and dementia did not receive or refuse the pneumonia vaccine, and there was no documentation of education or administration in their medical record. The facility's policy requires documentation of immunization status upon admission, but staff interviews revealed confusion over responsibility, with the Unit Manager unaware of the resident's vaccination status. The administrator was aware of issues but not the full extent.
A resident was not provided education or offered the COVID-19 vaccine, as required by the facility's policy. The resident's medical record lacked documentation of the vaccine being offered, administered, or declined, despite the resident having no cognitive impairment. Interviews with staff revealed confusion over responsibility for vaccine documentation, and the DON confirmed the resident had not received the vaccine or signed a declination.
Resident’s Right to Dignity and Freedom of Movement Not Respected
Penalty
Summary
A resident with Alzheimer's disease and a severe cognitive impairment, evidenced by a BIMS score of five on a recent quarterly MDS assessment, was observed self-propelling in a wheelchair near the nurses' station while verbalizing the need to use the bathroom. As the resident moved toward A Hall, a CNA approached from behind, stopped the wheelchair, and attempted to redirect the resident in another direction. The resident pointed down the hall and stated she wanted to go that way, but the CNA told her she did not need to go down there. The resident's tone elevated, and she began hitting the arm of her wheelchair while repeatedly stating she wanted to go toward A Hall. The CNA then grabbed the wheelchair handles, backed the resident up against the wall across from the nurses' station, and locked the wheelchair wheels to prevent her from moving down the hall or entering other residents' rooms. The resident's care plan, dated 10/27/2025, included goals to maintain her dignity and autonomy at the highest level, with interventions such as respecting her wishes and working with nursing staff to provide maximum comfort. The DON confirmed that restricting a resident's movement throughout the facility is against residents' rights and choices, and the Administrator stated that residents have the right to wander anywhere in the building, noting that residents are kept lined up in front of the nurses' station for more supervision. The facility's Resident Rights policy stated that each resident has the right to be treated with dignity and respect and that staff must honor and value each resident's input.
Failure to Follow PICC Line Care Protocols and Placement Verification
Penalty
Summary
A deficiency occurred when the facility failed to follow its own policy and physician's orders regarding the care and management of a resident's Peripherally Inserted Central Catheter (PICC) line. The facility's policy required weekly dressing changes for transparent dressings and dressing changes every 48 hours for gauze dressings, or as ordered by the physician. However, the resident reported that the PICC line dressing had not been changed since insertion, and observations confirmed that the dressing was not dated or timed, and included gauze under a transparent dressing. Staff interviews revealed inconsistent practices regarding dressing changes and a lack of adherence to established protocols. Additionally, after the PICC line was reinserted, a chest x-ray to confirm placement was not ordered or performed, despite this being a standard requirement and expectation communicated by the PICC line insertion company. The resident's medical record did not contain documentation of a chest x-ray following the new PICC line insertion, and the line was used for intravenous therapy without confirmation of proper placement. Interviews with staff, including the DON and ADON, confirmed that the chest x-ray was not completed and that the line had been used daily since insertion. During an observed dressing change, further deviations from protocol were noted, including a break in sterile technique, failure to change the stabilization device and antibacterial disk, and incomplete use of enhanced barrier precautions. The resident had a history of infection, recent surgical procedures, and required IV antibiotics via the PICC line. The facility's failure to follow established protocols and physician orders for PICC line care, dressing changes, and placement verification led to the identified deficiency.
Failure to Prevent Significant Medication Errors Due to Missed IV Antibiotic Doses
Penalty
Summary
A resident with a history of intraspinal abscess, infection following a procedure, candidiasis, COPD, asthma, depression, and muscle weakness was admitted and receiving IV antibiotic therapy via a PICC line for sepsis and infection. The resident's care plan included administration of IV antibiotics and fluids as ordered, with specific interventions for PICC line maintenance and monitoring for adverse reactions. Physician orders included Micafungin Sodium-NaCl IV solution to be given every 24 hours and Cefazolin Sodium injection every eight hours for a specified duration. Review of the Medication Administration Record (MAR) revealed multiple missed doses of both Cefazolin and Micafungin on several dates. The missed doses were marked as not given, and interviews with nursing staff indicated that when the PICC line was not usable or had come out, the antibiotics were not administered until the line was reinserted. The facility's policy required nurses to notify the physician if medication would be given late or to obtain an alternative order, but this protocol was not followed. The DON confirmed that the expectation was for nurses to contact the physician for an alternative route or order when the PICC line was not available.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Wound Care
Penalty
Summary
Staff failed to consistently follow infection control practices related to Enhanced Barrier Precautions (EBP) and hand hygiene during wound care for two residents receiving wound treatment. For one resident with a stage 4 pressure ulcer and significant cognitive impairment, a nurse performed a dressing change while following some EBP protocols, such as donning a gown and performing hand hygiene. However, the nurse did not use a barrier for wound care supplies, placed a multi-resident wound cleanser bottle directly on the bedside drawer, and returned the bottle to the treatment cart without sanitizing it. For another resident with multiple wounds, severe cognitive impairment, and a Foley catheter, staff did not wear gowns during high-contact wound care activities despite EBP signage on the door. The LPN removed soiled dressings and applied new ones without changing gloves or performing hand hygiene between steps. The LPN also used a personal marker while wearing contaminated gloves and returned it to her pocket without cleaning it. During the dressing change on a different wound, gloves were changed but hand hygiene was not performed after glove removal. Interviews with staff confirmed awareness of EBP protocols and the need for gowns and hand hygiene during high-contact care, but acknowledged lapses in practice. The Infection Preventionist and Director of Nursing both stated that staff were educated on these protocols and that expectations included consistent adherence to infection control practices, including hand hygiene and use of PPE for residents with wounds or indwelling devices.
Failure to Label and Store Personal Care Items Properly
Penalty
Summary
The facility failed to ensure proper labeling and storage of residents' personal care items, such as basins, urinals, and bedpans, in 11 out of 69 shared rooms. According to the facility's policy titled 'Giving a Bed bath,' these items should be labeled with the resident's name, placed in a clean plastic bag, and stored appropriately. However, observations revealed that many of these items were either unlabeled, unbagged, or placed directly on the floor, which contradicts the facility's policy and poses a risk of cross-contamination. During an inspection, the Infection Control Preventionist (ICP) confirmed the presence of numerous unlabeled and unbagged items in various shared bathrooms across different halls. The ICP acknowledged that Certified Nursing Assistants (CNAs) were responsible for ensuring that all personal care items were properly labeled and stored, but this was not consistently done. The failure to adhere to the established procedures for labeling and storing these items could potentially expose residents to infections due to cross-contamination.
Unauthorized and Unsecured Medications at Bedside
Penalty
Summary
The facility failed to ensure that three residents did not have unauthorized and unsecured medications at their bedside, which could lead to medication errors and unauthorized access by other residents. Resident R45, who had a moderate cognitive impairment, was found with over-the-counter medication on her bedside table. She was unaware that she was not allowed to have medications at the bedside, and her son had provided the medication. The facility's policy requires an interdisciplinary team to assess and approve self-administration of medication, but R45's records lacked such approval or a care plan for self-administration. Resident R113, also with moderate cognitive impairment, was found with a pill on his bedside table. He was unsure of its purpose and had not been assessed for self-administration of medications. A Licensed Practical Nurse confirmed that R113 was not capable of self-medication and that staff were required to supervise his medication intake. The Director of Nursing stated that the facility does not generally allow self-administration of medication without an assessment and permission. Resident R432, with intact cognition, was found with eye drop medication on her bedside table. She had not been assessed for self-administration, and her family had brought the medication from the hospital without the facility's knowledge. The facility's policy requires medications to be stored securely if self-administration is approved, but R432's records lacked a care plan or approval for self-administration.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for two residents, leading to deficiencies in addressing their specific medical needs. One resident, diagnosed with Methicillin-resistant Staphylococcus aureus (MRSA), was readmitted to the facility without a care plan addressing this infection. Despite the resident's condition being documented in various assessments and progress notes, the care plan did not reflect the necessary interventions for managing MRSA. Interviews with the LPN/MDS Coordinator and the Director of Nursing confirmed that the oversight occurred, and the care plan should have included measures for the infection. Another resident, who was dependent on supplemental oxygen due to conditions such as asthma and a malignant neoplasm, also lacked a care plan for oxygen therapy. The resident's medical records indicated a physician's order for continuous oxygen therapy, yet this was not incorporated into the care plan. Interviews with the LPN/MDS Coordinator and the Director of Nursing revealed that the absence of an oxygen therapy plan was an oversight, as the care plan should have reflected the resident's dependency on continuous oxygen.
Oxygen Therapy and Equipment Maintenance Deficiencies
Penalty
Summary
The facility failed to administer oxygen therapy in accordance with physician orders and maintain clean oxygen concentrator filters for several residents. One resident, who was admitted with asthma and dependence on supplemental oxygen, was observed receiving oxygen at a rate of 3 liters per minute, contrary to the physician's order of 2 liters per minute. This discrepancy was confirmed by the Director of Nursing and a Licensed Practical Nurse, who verified the physician's order in the facility's electronic records. Additionally, the facility did not ensure the cleanliness of oxygen concentrator filters for three residents. Observations revealed that the filters contained thick gray or dark brown substances, indicating they had not been cleaned as required. Interviews with the Director of Nursing and Licensed Practical Nurses confirmed that the responsibility for cleaning these filters fell on the Sunday night shift nurses, with rounds conducted on Monday mornings to ensure compliance. However, the observations indicated that the maintenance and cleaning of the oxygen equipment were not properly executed.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 7.69 percent for one resident. This deficiency was identified through observations, staff interviews, and record reviews. The facility's policy on administering medications requires that medications be administered safely, timely, and as prescribed, with the individual administering the medication verifying the right resident, medication, dosage, time, and method of administration. However, during a medication pass observation, an LPN administered an incorrect dosage of Linzess to a resident, giving two capsules of 290 mg each instead of the prescribed 145 mg capsules. Additionally, the LPN failed to prime the insulin pen needle before administering insulin, which could lead to the resident receiving a decreased dose. The resident involved had diagnoses including type 2 diabetes and irritable bowel syndrome. The LPN confirmed the error in dosage and acknowledged not priming the insulin pen, stating a lack of awareness of the need to prime the pen. The Director of Nursing emphasized the importance of following the five rights of medication administration and adhering to physician orders and manufacturer's guidelines. The DON noted that incorrect medication dosages could potentially cause adverse effects and that the insulin pen should be primed to ensure the correct dose is administered.
Failure to Provide Bed-Hold Policy Information
Penalty
Summary
The facility failed to provide written information about its bed-hold policy to residents or their representatives when transferring residents to the hospital. This deficiency was identified for three residents who were reviewed for bed hold. The facility's Bed-Hold Policy, revised in January 2011, requires that residents or their representatives be informed about the policy concerning reserving beds during hospital stays. However, the facility did not adhere to this policy, as evidenced by the lack of written communication provided to the residents or their families at the time of transfer. For instance, one resident was transferred to the hospital due to an ear infection and did not return to the facility. The family was informed by phone to remove the resident's belongings, as the bed was no longer available, without prior written notice about the bed-hold policy. Another resident, transferred due to edema and pain, did not recall receiving any written information about the bed-hold policy. A third resident, transferred due to respiratory distress, also did not receive any documentation regarding the bed-hold policy. Interviews with facility staff, including the MDS Coordinator and the DON, confirmed that the facility did not provide or send any information about the bed-hold policy to residents or their families during hospital transfers.
Failure in Antibiotic Stewardship Program Implementation
Penalty
Summary
The facility failed to properly implement its Antibiotic Stewardship program, as evidenced by the lack of assessment and determination of clinical indications for antibiotic use using the McGreer Criteria for two residents. Resident 16 was admitted with conditions including diabetes and cellulitis and was identified to have a positive urine culture for Escherichia coli and ESBL. Despite being started on antibiotics, there was no evidence of the McGreer criteria being used to justify the antibiotic treatment. Similarly, Resident 17, admitted with diastolic congestive heart failure and asthma, was also started on antibiotics following a positive urine culture for Escherichia coli and Proteus mirabilis, without documentation of the McGreer criteria being applied. The facility's policy on Antibiotic Stewardship, dated April 2022, outlines the need for a multidisciplinary program to monitor and guide antibiotic use, including the use of established guidelines for infection identification and treatment. However, the Infection Control Preventionist (ICP) admitted to not conducting infection surveillance due to a lack of training, and there was no documentation of signs and symptoms or the McGreer criteria worksheet for the residents involved. This lack of systematic protocols and documentation led to the deficiency in monitoring and assessing antibiotic use effectively.
Inadequate Management of Infection Control Program
Penalty
Summary
The facility failed to ensure that the designated Infection Control Preventionist (ICP) adequately assessed, developed, implemented, monitored, and managed the Infection Control and Prevention (IPCP) program. This deficiency was identified through a review of records, interviews, and the facility's policy titled Infection Control - Infection Preventionist. The policy mandates that a qualified professional be employed to establish and maintain an infection control and prevention program. However, the ICP did not fulfill these responsibilities, which included implementing a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases. The ICP also failed to ensure the implementation of an antibiotic stewardship program and did not update her infection control training since November 2022. The facility's census was 136 at the time of the survey, and the lack of adequate infection control measures created the potential for an ineffective program, placing residents at risk for the transmission of infections and communicable diseases. The ICP had completed the CDC Nursing Home Infection Preventionist Training Course in November 2022, but no further training or education was obtained since then. The facility's Administrator acknowledged awareness of some issues but was not fully aware of the extent of the deficiencies. The report cross-references deficiencies F880, F881, F883, and F887.
Environmental Deficiencies in Facility Maintenance
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and visitors, as evidenced by several observations and interviews. In room C14, the wallpaper was peeling away from the wall, and there were large brown water stains on the ceiling tiles, indicating a lack of maintenance and repair. Additionally, the exterior of the facility was not aesthetically appealing, with garbage and debris such as tissues, paper, disposable cups, and a face mask scattered in the parking lot, on the sidewalk, and inside the covered porch at the front entrance, despite the presence of a trash bin nearby. The porch area at the entrance of the facility was also found to be unclean and unsafe due to the presence of cat hair on the outdoor furniture cushions and a strong odor of cat urine. Residents expressed their discomfort and reluctance to use the porch area due to the presence of cats, which were seen jumping out from behind bushes near the entrance. The Activity Assistant acknowledged the issue, noting that one resident feeds the cats, which contributes to the problem. The Environmental Director confirmed the unsightly condition of the area and acknowledged the need for regular cleaning, especially during peak visitor times.
Failure to Address Communication Needs in Care Plans
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans addressing communication needs for four residents. Resident 4, who had a cochlear implant and moderate hearing difficulty, did not have a care plan focusing on hearing loss. Resident 18, with severe cognitive impairment and a preferred language of Korean, lacked a care plan addressing her inability to speak English. Staff communicated with her using hand gestures. Resident 26, with moderate cognitive impairment and a preferred language of Spanish, also lacked a care plan for his language barrier. He communicated with staff using gestures, and there were no communication boards available. Resident 27, who preferred Vietnamese and had no cognitive impairment, was unable to consistently communicate in English and did not have a care plan addressing this issue. The MDS Coordinator confirmed that the care plans were not person-centered to reflect the residents' communication needs.
Deficiency in CMT Competency for Insulin Administration
Penalty
Summary
The facility failed to ensure that Certified Medication Technicians (CMTs) met professional standards of quality in administering insulin to residents. Specifically, three out of five CMTs (CMT MM, CMT LL, and CMT FF) were found to lack documented competencies in insulin administration. CMT MM, hired on March 8, 2024, admitted to not having completed skills competencies at the current facility, although she had done so at her previous job. There was no Medication Administration - Subcutaneous Injection checklist completed for CMT MM. CMT LL, hired on August 22, 2022, was unaware of the requirement to have insulin dosages verified by a licensed nurse, as per the Georgia State Certification Medication Aide policy. Her Medication Administration - Subcutaneous Injection checklist was unsigned. CMT FF, hired on November 11, 2020, was uncertain about her yearly competencies related to insulin administration, and her checklist was also unsigned. The Staff Development Coordinator confirmed the lack of competency documentation specific to insulin administration for the CMTs, indicating a systemic issue in ensuring proper training and verification processes.
Medication Administration Failures
Penalty
Summary
The facility failed to ensure medications were administered as ordered for two residents, R17 and R25, leading to missed doses of critical medications. R17, who was cognitively intact and had diagnoses including COPD and asthma, missed 20 doses of her Xopenex inhaler and 13 doses of Atorvastatin over two months. During a resident council meeting, R17 expressed concerns about running out of medications and the facility's lack of care in ensuring medication availability. Similarly, R25, who had moderate cognitive impairment and suffered from diabetes and neuralgia, missed seven doses of Pregabalin. R25 also reported delays in receiving medications, taking two to three days for reorders. Interviews with facility staff revealed systemic issues contributing to the medication administration failures. The Nurse Practitioner acknowledged the problem of medications not being administered on time. The Director of Nursing cited challenges with insurance companies requiring repeated prior authorizations, which contributed to medication delays. The Pharmacy Consultant indicated that nurses should be able to obtain medications through the pharmacy's website or by calling, but was unaware of any issues related to prior authorizations. The facility's policies on pharmacy services and medication delivery expectations were not effectively implemented, resulting in the deficiencies observed.
Insulin Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure proper administration of insulin as ordered for three residents, leading to significant medication errors. For Resident 15, there were multiple instances where insulin was not administered according to the sliding scale orders, despite blood sugar levels indicating the need for insulin. Specifically, there were 16 occasions where insulin was not given when blood sugar levels were between 0-160, and additional instances where blood sugar levels exceeded 160 but insulin was not administered. This included a blood sugar reading of 363 on one occasion and 347 on another, both without corresponding insulin administration. Resident 11 also experienced discrepancies in insulin administration. The November 2023 MAR showed inconsistencies between recorded blood sugar levels and the sliding scale documentation, with insulin not administered when required. There were 28 instances where 'NA' was used incorrectly, and specific dates where insulin was not given despite high blood sugar readings. Similar issues persisted into December 2023, with discrepancies between blood sugar documentation and insulin administration, including instances where insulin was administered based on incorrect blood sugar readings. For Resident 5, the January 2023 MAR revealed that insulin was not administered according to sliding scale orders on multiple occasions, including a blood sugar reading of 253 and another of 397. In February 2023, there were further instances of missing documentation for blood sugar checks and insulin administration. Notably, a blood sugar reading of 40 was recorded without documentation of physician notification or resident condition. Interviews with the Nurse Practitioner and Director of Nursing highlighted a lack of awareness and oversight regarding these insulin administration issues.
Failure to Implement Enhanced Barrier and Transmission-Based Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) and transmission-based precautions (TBP) for two residents, R19 and R20, which could lead to cross-contamination and infection spread. For R19, who was readmitted with conditions including a cerebral vascular accident and multiple pressure sores, the facility did not ensure that personal protective equipment (PPE) was used during wound care. An LPN was observed providing wound care without wearing a gown, and the EBP signage was not visible, being placed on the floor behind the door. The LPN was unaware of the need for EBP for R19, indicating a lack of communication and training. For R20, who was admitted with pneumonia, open wounds, and a PICC line, the facility delayed implementing TBP. A CNA placed PPE and TBP signage on the door seven days after admission, and the Unit Manager admitted to not being aware of R20's MRSA status until reviewing discharge paperwork. The Infection Control Preventionist (ICP) was not present the previous week, and the signage was not appropriately placed, leading to confusion among staff. The Unit Manager was responsible for ensuring visibility of EBP and TBP signage and accessibility of PPE, but this was not adequately managed.
Failure to Update Care Plan for Sacral Pressure Ulcer
Penalty
Summary
The facility failed to revise a resident's person-centered comprehensive care plan to include interventions for a sacral pressure ulcer. The care plan, which should be updated when there is a significant change in the resident's condition, did not reflect the presence of an unstageable sacral pressure ulcer for a resident who was readmitted with diagnoses including cerebral vascular accident with right-sided paralysis, seizures, and vascular dementia. The care plan was last revised to address new wounds on the resident's legs and heel but did not include the sacral pressure ulcer. The MDS Coordinator confirmed during an interview that the care plan for the resident's skin impairment had not been updated to include the unstageable sacral wound, despite the facility's policy requiring such updates. This oversight placed the resident at risk for unmet care needs, as the care plan did not incorporate necessary interventions for the sacral pressure ulcer, which was identified in a wound evaluation and management summary.
Expired Insulin Vials Found on Medication Carts
Penalty
Summary
The facility failed to ensure that expired insulin vials were removed from two of five medication carts, which placed residents at risk of receiving ineffective medications. During an inspection of the B-Hall medication cart, an LPN confirmed that a vial of Lantus insulin, opened on 6/1/2024, had been used beyond its 28-day expiration period. Additionally, an inspection of the C-Hall medication cart revealed a vial of Novolog insulin without an open or use-by date, and the LPN confirmed that this insulin had been administered to a resident without knowledge of its expiration. Interviews with the facility's pharmacist and the Director of Nursing (DON) highlighted ongoing issues with expired medications. The pharmacist, who conducts monthly cart monitoring, acknowledged the persistent problem of expired insulins at the facility and noted that nurses are responsible for checking medication carts for expired medications. The DON confirmed that expired medications should not be available for use and should be removed immediately from medication carts.
Failure to Document and Administer Pneumonia Vaccine
Penalty
Summary
The facility failed to provide education, offer, or administer the pneumonia vaccination to a resident diagnosed with Alzheimer's disease and dementia. Upon review of the resident's clinical record, it was found that there was no documentation of the pneumonia vaccine being administered or refused since the resident's admission. The facility's policy mandates that the pneumococcal immunization status be determined and documented for each resident upon admission, including education on the benefits and potential side effects of the vaccine. However, this was not adhered to in the case of the resident in question. Interviews with facility staff revealed a lack of clarity and responsibility regarding the resident's immunization status. The Infection Control Preventionist indicated that the responsibility for documenting immunizations lies with the Unit Managers. However, the Unit Manager interviewed was unaware of the resident's pneumonia vaccination status and confirmed the absence of documentation in the electronic medical record. The facility administrator acknowledged awareness of some issues but was not informed of the extent of the deficiency.
Failure to Educate and Document COVID-19 Vaccination for Resident
Penalty
Summary
The facility failed to provide education and offer the COVID-19 vaccine to one of the sampled residents, identified as R19, as per their policy on infection control and immunizations. The policy mandates that residents receive education on the benefits, risks, and potential side effects of the SARS-CoV-2 vaccine before it is offered, and that documentation of the education and the resident's decision is maintained in the medical record. However, a review of R19's clinical record revealed no documentation of the COVID-19 vaccine being offered, administered, or declined. R19, who was admitted with diagnoses including cerebral vascular accident and vascular dementia, had a BIMS score indicating no cognitive impairment, suggesting they were capable of making informed decisions regarding vaccination. Interviews with facility staff, including the Infection Control Preventionist, the LPN Unit Manager, and the Administrator, revealed a lack of clarity and responsibility regarding the documentation and administration of COVID-19 vaccines. The Infection Control Preventionist indicated that unit managers were responsible for immunization documentation, while the LPN Unit Manager could not recall any information about R19's COVID-19 vaccination status. The Director of Nursing confirmed that R19 had neither received the vaccine nor signed a declination form, highlighting a gap in the facility's adherence to its own immunization policy.
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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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