Cartersville Center For Nursing And Healing
Inspection history, citations, penalties and survey trends for this long-term care facility in Cartersville, Georgia.
- Location
- 78 Opal Street, Cartersville, Georgia 30120
- CMS Provider Number
- 115571
- Inspections on file
- 21
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Cartersville Center For Nursing And Healing during CMS and state inspections, most recent first.
Surveyors found that food items were not consistently labeled or stored properly, kitchen equipment was not maintained or cleaned as required, and staff failed to follow facility policies for food brought in by families. Observations included unlabeled and improperly stored food, unclean coffee cups, and a ceiling fan with significant buildup above the dish area. Maintenance issues, such as a faulty freezer latch and ice buildup, were not reported or addressed in a timely manner, contributing to unsanitary conditions affecting most residents.
The facility experienced a medication error rate of 17.24%, significantly above the acceptable threshold, due to multiple instances of omitted doses, late administration, and failure to follow proper medication administration procedures. Errors included missed doses of prescribed medications, lack of instruction for inhaler use, and delays caused by medication unavailability, as confirmed by staff interviews and pharmacy records.
Two residents with Foley catheters were observed without privacy bags covering their urinary drainage bags, despite facility policy and staff expectations that privacy covers be used at all times. LPNs and the DON confirmed that privacy bags should be in place and checked regularly, but observations showed this was not consistently done.
A resident with multiple chronic conditions was discharged home, but the facility incorrectly coded the discharge in the MDS as a hospital transfer and did not transmit a correction to CMS as required. Staff interviews revealed oversight and uncertainty in the discharge coding process, and the error was not identified or corrected in a timely manner.
A resident with multiple chronic conditions did not receive two prescribed medications at the scheduled time due to delays in pharmacy delivery and insurance denial, despite staff efforts to locate and reorder the medications. The facility's procedures for acquiring and administering medications were not effectively followed, resulting in the resident missing doses as ordered.
Multiple residents with various medical conditions were moved between rooms without receiving the required written notice or advance explanation, despite facility policy and federal regulations mandating such notification. Staff interviews confirmed that only verbal communication and EHR updates were used, and residents reported not being given written notice or the opportunity to express their preferences regarding room changes.
The facility did not provide timely access to or copies of medical records for three residents after written requests were made by legal representatives or next of kin. In each case, significant delays occurred, with records being provided only after 35, 39, and 116 days, far exceeding the required two-working-day timeframe. Staff and compliance company interviews confirmed that the process for handling such requests was routinely delayed, particularly for discharged residents or when legal representatives were involved.
The facility failed to follow its policies on food storage, preparation, and sanitation, affecting 108 residents. Observations revealed improperly labeled and expired food items, unclean ice machines, and incorrect thawing procedures. The morning cook did not adhere to the puree recipe, and expired apple juice was found in emergency supplies. These issues indicate lapses in food safety protocols.
A facility failed to inform a resident's responsible party about new medication orders, despite the resident's religious beliefs against taking medications. The resident was receiving multiple medications without the responsible party's knowledge. Staff interviews revealed a lack of adherence to the expectation of notifying family and responsible parties about medication changes.
The facility failed to ensure accurate MDS assessments for two residents. One resident's MDS inaccurately documented the presence of a Foley catheter, which had been removed, while another resident's MDS did not reflect their reported pain despite having a care plan for pain management. These discrepancies highlight a failure to update assessments accurately based on current conditions and resident feedback.
The facility failed to provide scheduled showers for two residents dependent on staff for ADLs. One resident received only one shower during the observed period, while another received six out of 13 scheduled showers. Staff interviews revealed issues with EMR documentation, and the administration could not provide evidence of resident refusals for missed showers.
A resident expressed concerns about the lack of a television and activities in his room after being moved. Despite requests, no activities were introduced, and the Activities Department had staffing issues. The facility's policy required activities based on assessments, but this was not followed for the resident.
A resident with multiple medical conditions did not receive prescribed compression stockings and ointment as per physician's orders. Observations showed the resident's legs were discolored and swollen, and staff interviews revealed a lack of awareness and communication regarding the orders.
A resident's room contained unsecured O2 tanks, one without a regulator and covered with a plastic cap, indicating it was full. Facility policy requires O2 tanks to be stored securely outside the resident's room, but this was not followed. Staff interviews confirmed the tanks should not have been in the room, highlighting a deficiency in adhering to safety protocols.
A resident with a history of leg and back pain did not receive prescribed pain medication due to it being out of stock. Despite a care plan and a new order, the medication was not retrieved from the emergency system, leading to the resident experiencing increased pain for over six hours. The issue was resolved later when the medication was finally administered, reducing the pain to zero.
The facility failed to secure a medication cart and properly organize the medication storage room, leading to potential unauthorized access and misuse of medications. An LPN left a medication cart unlocked, and the storage room contained expired and used items mixed with new ones. Staff interviews confirmed the oversight and lack of proper labeling, contributing to the deficiency.
A facility failed to maintain accurate documentation for a resident with multiple health conditions, including cellulitis and heart failure. Despite physician orders for daily skin assessments, wound care, and compression stockings, records inaccurately reflected care provided. Observations and interviews revealed discrepancies, with the resident not receiving documented treatments. Nursing staff confirmed the inaccuracies, highlighting a failure to document care truthfully.
The facility failed to maintain infection control protocols during catheter insertion, medication administration, and contact isolation. An LPN did not perform hand hygiene between changing sterile gloves, compromising sterile technique. Another LPN failed to perform hand hygiene during medication preparation. Additionally, doors to rooms of residents on contact precautions were left open, contrary to protocol. These deficiencies were confirmed by staff interviews and observations.
A facility failed to follow proper infection control practices for a resident on contact isolation for MRSA. An LPN entered the resident's room without washing hands or wearing gloves and a gown, and continued to prepare medications for other residents without sanitizing hands. The breach in protocol was confirmed by the Infection Control Preventionist and the Director of Nursing.
Deficient Food Storage, Labeling, and Kitchen Sanitation
Penalty
Summary
The facility failed to ensure that food was labeled, stored, and prepared under sanitary conditions, as well as to maintain cleanliness and proper functioning of kitchen equipment. During an observation tour, multiple food items on the steam table were found covered in plastic wrap and labeled with preparation dates, but the reason for their placement was unclear, and a box of powdered sugar was open, unsealed, and unlabeled. In the walk-in refrigerator, a carton of liquid whole eggs was found open and without an open date, and in the walk-in freezer, a large package of meat was wrapped in plastic wrap but not labeled or dated. The freezer also had ice buildup due to a door latch that did not secure properly, and there was no record of maintenance being notified about this issue for several months. Further observations revealed that coffee cups described as clean and ready for use had an orange-colored film inside, and a ceiling fan above the dishwasher and dish area was covered with a buildup of fuzzy grey matter. In a pantry refrigerator, a box of take-out chicken brought in by family was found with only a room number written on it, lacking the required resident name and date. Staff interviews confirmed that perishable foods brought in by family should be labeled with the resident's name and date, and items older than three days should be discarded, but these procedures were not followed. The facility's policies required food service employees to comply with safe food handling practices, proper labeling and storage of perishable foods, and regular cleaning and maintenance of equipment. However, these policies were not consistently implemented, as evidenced by the lack of labeling, improper storage, unclean equipment, and failure to report or address maintenance issues in a timely manner. These deficiencies affected the majority of residents receiving meals from the kitchen.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed error rate of 17.24% during medication administration for four residents. Specific errors included omitted doses, such as polyethylene glycol for one resident and a Nepro supplement for another due to unavailability. Additionally, a resident was not instructed to rinse his mouth after using an inhaler, and another resident's medications were delayed or omitted due to issues with medication availability and timing. One LPN was observed to be significantly behind schedule during the morning medication pass, with more than half of the residents on her cart still awaiting their 9:00 am medications well after the scheduled time. Interviews with nursing staff and management confirmed expectations that medications should be administered within one hour before or after the scheduled time, and that medications should be ordered in advance to prevent running out. Pharmacy records and staff interviews revealed that some medications were not available at the time of administration, despite being ordered previously, and that there was no drug shortage for the omitted medications. The combination of omitted doses, late administration, and failure to follow proper medication administration procedures contributed to the elevated medication error rate.
Failure to Provide Privacy Bags for Catheter Drainage Bags
Penalty
Summary
The facility failed to provide privacy bags for urinary drainage bags on Foley catheters for two residents, as required by facility policy. Observations revealed that one male resident with diagnoses including urinary retention, chronic kidney failure, and congestive heart failure was seen in both the therapy room and dining room without a privacy cover on his catheter drainage bag. Another resident was observed in bed with a Foley catheter and no privacy cover in place. The facility's policy states that privacy bags should be available and used at all times, and replaced when soiled, with a catheter change, or as needed. Interviews with LPNs confirmed that all residents with catheters are expected to have privacy bags, and that this should be checked by both nurses and CNAs. The DON also stated that privacy bags should be put in place on admission if not already present. Despite these expectations and policies, the lack of privacy covers was observed on multiple occasions for both residents, indicating a failure to follow established catheter care protocols.
Failure to Accurately Code Resident Discharge and Transmit Correction to CMS
Penalty
Summary
The facility failed to properly code a resident's discharge in accordance with its policy and federal requirements. Specifically, for one resident with multiple chronic conditions, the Minimum Data Set (MDS) was inaccurately coded as a discharge to a hospital when the resident had actually been discharged home. The facility's policy requires that discharge assessments be completed using the discharge date as the Assessment Reference Date (ARD) and that corrections be transmitted to CMS if errors are identified. However, no correction transmittal was sent to CMS for this resident, and the error was not identified or corrected in a timely manner. Interviews with the MDS Coordinator and Remote MDS Coordinator revealed uncertainty and oversight regarding the correct discharge coding for the resident. The MDS Coordinator was unsure why the resident was coded as a hospital discharge, and the Remote MDS Coordinator acknowledged that the discharge should have been coded as 'return not anticipated' and that a correction should have been made. The DON stated that she expected the MDS process to be checked and rechecked to ensure accuracy, but this did not occur in this instance.
Failure to Provide Timely Pharmaceutical Services
Penalty
Summary
The facility failed to provide routine and emergency pharmaceutical services to meet the needs of a resident, as required by policy and regulation. Specifically, a resident with multiple chronic conditions, including chronic kidney disease, diabetes, heart failure, and atrial fibrillation, did not receive two ordered medications—apixaban and Spiriva—at the scheduled time. Observations during medication pass revealed that both medications were missing from the medication cart, and staff were unable to locate apixaban in the emergency stock. After contacting the nurse practitioner, orders were received to hold the medications due to their unavailability. The resident eventually received the available medication later in the morning, but Spiriva remained unavailable. Interviews with staff and pharmacy personnel revealed that apixaban had been ordered several days prior and was only delivered the night before, while Spiriva had not been filled due to an unexplained delay and subsequent insurance denial. The pharmacy cited staffing shortages and indicated that medication turnaround should typically be 24 hours. Facility staff reported that medication reordering should occur a week in advance, and if medications are unavailable, the pharmacy and prescriber are contacted. Despite these procedures, the resident did not receive all prescribed medications as ordered, constituting a failure to ensure timely access to necessary pharmaceutical services.
Failure to Provide Written Notice of Room Changes
Penalty
Summary
The facility failed to provide written notice to residents or their responsible parties prior to making room changes, as required by both facility policy and federal regulation. This deficiency was identified through interviews, record reviews, and policy examination, affecting four residents who experienced multiple room changes. The facility's policy states that written notice, including the reason for the move, must be given in advance in a language and manner the resident and representative understand. However, documentation and interviews revealed that only verbal notifications or phone calls were made, and no written notifications were provided. Residents affected by this deficiency had varying medical histories, including end stage renal disease, congestive heart failure, schizophrenia, diabetes mellitus, and chronic obstructive pulmonary disease. Cognitive assessments showed that most residents had intact cognition, with one resident having moderate cognitive impairment. Despite their cognitive abilities, these residents were not given written notice or the opportunity to express their preferences regarding room changes. Progress notes and census reports confirmed multiple room changes for each resident without evidence of written notification. Staff interviews, including those with CNAs, LPNs, RNs, the Social Services Director, the DON, and the Administrator, consistently indicated that the process for room changes involved verbal communication and updates in the electronic health record, but not written notification. Staff were generally unaware that written notice was a regulatory requirement. Residents reported being moved without advance notice or written communication, and some expressed dissatisfaction with the lack of choice or information about the moves. The deficiency was systemic, as no staff member reported providing written notice for any room change.
Failure to Timely Provide Resident Medical Records
Penalty
Summary
The facility failed to provide written copies of residents' medical records within two working days of initial written requests for three residents, as required by both facility policy and federal regulations. The policy specified that residents or their legal representatives should receive access to their records within 24 hours and copies within two working days, with a possible extension if notification is provided. However, in all three cases reviewed, significant delays occurred, and the records were not provided within the required timeframe. For one resident with severe cognitive impairment and a history of Alzheimer's disease and vascular dementia, a law firm representing the resident sent a written request for medical records, which was received and signed for by the facility. Despite this, the process to obtain the records took 39 calendar days, involving multiple communications between the facility, a compliance company, and former facility owners. The delay was attributed to the need for verification, gathering records from previous owners, and waiting for payment before release. Another resident, who was cognitively intact and had a history of atrial fibrillation and COPD, had a medical records request faxed to the facility by a law firm. The process to provide access to the records took 35 calendar days, with the compliance company and facility staff involved in compiling and verifying the records before release. In the third case, a resident with severe cognitive impairment and multiple comorbidities had a request for records made by their next of kin, followed by repeated unsuccessful attempts by a law office to contact the facility. The records were not made available until 116 calendar days after the initial request. Interviews with staff and the compliance officer confirmed that the facility's process routinely failed to meet the required 48-hour or two-working-day timeframe, especially for requests involving discharged residents or legal representatives.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to its policies regarding food storage, preparation, and sanitation, which had the potential to affect 108 residents receiving oral diets. During a kitchen tour, it was observed that various food items in the walk-in refrigerator and freezer were not properly labeled or dated, and some dry storage foods were expired. The Dietary Manager confirmed these issues and acknowledged that the morning kitchen staff, including himself, were responsible for checking labeling, storage, and dates. Additionally, a black substance was found on the ice machines, indicating a lack of proper cleaning, as no cleaning log was presented, and the last deep cleaning was recorded months prior. Further observations revealed improper thawing procedures, with ground beef being thawed under hot running water, contrary to the facility's policy. The morning cook also deviated from the puree recipe process, using a beef base on uncooked pork ribs instead of following the prescribed method. This was confirmed by the Dietary Director, who noted the cook's actions. Additionally, expired apple juice was found in the emergency preparedness supplies. These deficiencies highlight lapses in following established protocols for food safety and sanitation within the facility.
Failure to Notify Responsible Party of Medication Changes
Penalty
Summary
The facility failed to notify the responsible party of new medication orders for a resident, identified as R315, who was part of a sample of 63 residents. The resident's daughter expressed concern about the facility's lack of communication regarding her mother's medication regimen, noting that her mother, a high religious dignitary, did not believe in taking medications except for blood pressure medication. A review of the electronic medical record showed that the only documented conversations with the responsible party were not related to medication and occurred on 3/8/2024 and 4/19/2024. Despite this, the resident was prescribed and receiving multiple medications, including Topamax, Depakote, Ivermectin, and Lexapro, without the responsible party being informed. Interviews with facility staff, including a registered nurse and the Director of Clinical Services, revealed a lack of awareness and adherence to the expectation that family and responsible parties should be notified of any changes in medication orders.
Inaccurate Resident Assessments in MDS Documentation
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, R413 and R68, as required by their policy on the Minimum Data Set (MDS). For R413, an observation and interview revealed that the resident was alert, oriented, and capable of performing certain activities independently, such as using the restroom. However, the MDS assessment inaccurately documented the presence of a Foley catheter, which had been removed earlier in the month. This discrepancy between the resident's current condition and the documented assessment indicates a failure to update the MDS accurately. For R68, the quarterly MDS assessment showed intact cognition and independence in activities of daily living, but it failed to accurately reflect the resident's pain status. Despite having a care plan that acknowledged potential pain due to neuropathy and pressure ulcers, the MDS did not document any pain issues. During an interview, R68 reported experiencing pain in both feet and taking medication as needed. The RN interviewed acknowledged that pain assessments should include detailed descriptions and interventions based on the assessment, orders, and care plan, which was not reflected in the MDS documentation.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to provide scheduled showers or baths for two residents who were dependent on staff for activities of daily living (ADLs). Resident R10, diagnosed with chronic obstructive pulmonary disease, hypertensive chronic kidney disease, and unspecified osteoarthritis, was scheduled for bathing three times a week and as needed. However, records indicated that R10 received a shower only once during the observed period, despite expressing a desire for more frequent showers. Similarly, Resident R45, with diagnoses including Parkinsonism and neurocognitive disorder with Lewy bodies, was scheduled for bathing three times a week and as needed but received showers only six out of the 13 scheduled times. Interviews with staff revealed issues with documentation and understanding of the electronic medical record (EMR) system. A Certified Nursing Assistant (CNA) admitted to difficulties in using the EMR system, which may have contributed to incomplete records. The facility's administration claimed sufficient staffing to meet shower schedules but could not provide documentation of resident refusals when showers were missed. The lack of documentation and adherence to scheduled care routines led to the identified deficiency in providing necessary ADL support to the residents.
Failure to Provide Activities Program for Resident
Penalty
Summary
The facility failed to develop and introduce an activities program for a resident, identified as R413, which had the potential to place the resident at risk for a diminished quality of life. The resident, who was awake and alert, expressed concerns about being moved into a room without a television, which was his only source of entertainment. Despite his requests for a television and inquiries about activities, no one had spoken to him about available activities. The facility's policy stated that activities should be based on comprehensive assessments and care plans, but the resident was not informed or included in any activities. Observations over several days confirmed that the resident did not have a television in his room and had not been visited by the Activities Department. Interviews with the Administrator and Activities Director revealed that there were staffing issues in the Activities Department, and the expected process of conducting initial assessments and follow-ups was not followed for this resident. The Administrator confirmed that the facility provides televisions for residents, but this had not been addressed for R413. The Activities Director was not familiar with the resident and confirmed there was no additional documentation for activities for him.
Failure to Follow Physician's Orders for Compression Stockings and Ointment
Penalty
Summary
The facility failed to adhere to the physician's orders for a resident, identified as R413, who was admitted with conditions including cellulitis, lymphedema, venous insufficiency, and heart failure. The orders included a skin assessment every Friday, application of Dermaphor ointment twice daily for dry skin, and the use of compression stockings every morning to be removed at bedtime. Observations revealed that the resident did not have compression stockings on multiple occasions, and his legs showed signs of discoloration, swelling, and extremely dry, scaly skin. The resident reported that the compression stockings had been removed several days prior and had not been reapplied, and that no ointment had been applied to his legs. Interviews with staff indicated a lack of awareness and communication regarding the physician's orders. LPN II was unaware of the order for compression stockings and noted that it did not appear on the Medication Administration Record (MAR), while LPN JJ confirmed the orders were present on the MAR. The Treatment Nurse stated that topical treatments were administered by unit nurses, and RN LL indicated that the Treatment Nurse managed wounds and assessed skin as needed. This lack of adherence to the physician's orders had the potential to place the resident at risk for medical complications and a diminished quality of life.
Improper Storage of Oxygen Tanks in Resident's Room
Penalty
Summary
The facility failed to ensure the safe and appropriate storage of oxygen (O2) tanks for a resident, leading to a deficiency. During an observation, it was noted that a resident had two O2 tanks in their room, one of which was not secured in a holder. The facility's policy requires that O2 tanks be stored in a designated, secure location to prevent accidents and hazards. However, the tanks were found in the resident's room, with one tank lacking a regulator and covered with a plastic cap, indicating it was full. Additionally, there was no signage indicating O2 usage on the resident's room door, and the resident's records showed no physician orders for O2 usage. Interviews with facility staff, including a registered nurse unit manager, the administrator, and a respiratory therapist, confirmed that the O2 tanks should not have been in the resident's room and should have been stored securely outside the facility. The staff acknowledged the potential danger posed by unsecured O2 tanks, which could cause injury if they fell. The facility's policy and staff interviews highlighted the responsibility of staff to ensure O2 tanks are properly stored and secured, yet this was not adhered to in this instance, resulting in a deficiency.
Failure in Pain Management for Resident
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as R68, who was admitted with diagnoses including pain in both legs, low back pain, and neuropathy. Despite having a care plan that included administering pain medication and non-pharmacological interventions, the facility did not have the prescribed oxycodone acetaminophen in stock during a medication administration observation. When the resident complained of pain at a level seven out of ten, the LPN discovered the medication was unavailable and attempted to substitute it with Tylenol, which did not alleviate the resident's pain. The resident's pain increased to eight out of ten, and no follow-up assessment was conducted for over six hours, contrary to the facility's pain management policy. The LPN and Unit Manager failed to retrieve the medication from the emergency management backup system, even after a new order was signed. The resident remained in pain until the medication was finally administered later in the day, reducing the pain to zero. The facility's failure to follow its pain management protocol resulted in the resident experiencing prolonged pain.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored securely and appropriately, as observed during a survey. A medication cart was left unlocked and unattended by an LPN, which was confirmed during an interview with the LPN who admitted forgetting to lock the cart. This oversight had the potential to allow unauthorized access to medications by residents, staff, or visitors. Additionally, the facility's medication storage room was found to be disorganized, with expired and used items co-mingled with new items, and various pharmacy items improperly stored in bags, a sink, and a storage box. During a tour of the medication storage room, it was observed that there were several issues, including a Foley Catheter with an open outer layer and an expired date, a laundry basket full of resident medication cards awaiting disposal, and a sink filled with various items such as IV fluids and tubing. Interviews with staff, including an LPN and the Unit Manager, revealed that the used items should have been discarded and not returned to the storage room. The Unit Manager confirmed that the items in brown bags were not marked as 'Do Not Use' and were supposed to be picked up by the pharmacy, but this had not occurred. The lack of proper labeling and organization in the medication storage room contributed to the potential for misuse of medications and biologicals.
Inaccurate Documentation of Resident Care
Penalty
Summary
The facility failed to maintain accurate documentation of care and services provided for a resident, identified as R413. The facility's policy on medical record documentation requires that each resident's medical record accurately represent their experiences with complete, accurate, and timely documentation. However, a review of R413's clinical records revealed discrepancies in the documentation of care. The resident was admitted with conditions including cellulitis, lymphedema, venous insufficiency, and heart failure. Physician orders included daily skin assessments, wound care with Dermaphor ointment, and the use of compression stockings. Despite these orders, the medication administration record (MAR) indicated that wound care and compression stocking application were documented as performed on specific dates, but observations and resident interviews contradicted this documentation. On multiple occasions, R413 was observed without compression stockings, and the resident reported that no ointment had been applied to their legs. Interviews with nursing staff confirmed the discrepancies in documentation. An LPN acknowledged the orders and documentation but did not provide further clarification. An RN confirmed the documentation of compression stockings and ointment application, as well as urinary catheter care, which was documented after the catheter's removal. The RN stated that staff are expected to document only what they perform and not falsify records, highlighting a failure in maintaining accurate and truthful documentation of care provided to the resident.
Infection Control Protocol Failures in LTC Facility
Penalty
Summary
The facility failed to maintain infection control protocols during the insertion of an indwelling urinary catheter for a resident with a neurogenic bladder. The Licensed Practical Nurse (LPN) involved did not perform hand hygiene between changing sterile gloves and compromised the sterile technique by fanning the gloves in the air and coiling the catheter in her hand without its sterile packaging. This lapse in protocol was acknowledged by the LPN and confirmed by another LPN present during the procedure. Another deficiency was observed during medication administration for a resident. An LPN did not perform hand hygiene after leaving the medication cart to retrieve multivitamins from the medication storage room and returning to complete medication preparation. This was confirmed by the LPN during an interview. Additionally, the facility failed to adhere to contact isolation protocols for two residents diagnosed with infectious conditions. Observations revealed that the doors to the rooms of these residents, who were on contact precautions, were left open despite signage indicating they should remain closed. The Infection Preventionist confirmed that it was expected for the doors to be closed to prevent the spread of infection.
Failure to Follow Infection Control Practices for Resident on Contact Isolation
Penalty
Summary
The facility failed to follow proper infection control practices for a resident on contact isolation. Specifically, a Licensed Practical Nurse (LPN) entered the resident's room without washing or sanitizing her hands, and without wearing gloves or a gown, despite the resident being on contact isolation for MRSA. The LPN also failed to wash or sanitize her hands after leaving the room and continued to prepare medications for other residents, thereby potentially spreading the infection. The facility's policy on hand hygiene and the use of personal protective equipment (PPE) was not followed, as confirmed by the Infection Control Preventionist and the Director of Nursing. The resident involved had a medical history that included acute renal failure, diarrhea, possible clostridium difficile, and a urinary tract infection with MRSA. The care plan for this resident required staff to wear gowns and masks when in contact with the resident. Despite clear signage on the resident's door indicating contact precautions and the need for hand hygiene and PPE, the LPN did not adhere to these protocols. This lapse in infection control was acknowledged by the LPN, who admitted to forgetting the resident's isolation status, and by the Infection Control Preventionist and the Director of Nursing, who confirmed the breach in protocol.
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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