Fairburn Heights Of Journey Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Fairburn, Georgia.
- Location
- 178 West Campbellton Street, Fairburn, Georgia 30213
- CMS Provider Number
- 115298
- Inspections on file
- 22
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Fairburn Heights Of Journey Llc during CMS and state inspections, most recent first.
The facility did not ensure menus were prepared in advance with required details such as serving sizes and diet-specific modifications. After a kitchen fire, staff relied on emergency menus but failed to provide clear documentation or guidance for dietary modifications and portion sizes. Residents received meals that did not match planned menus, and dietary staff lacked instructions for preparing meals according to individual diet orders, placing all residents at risk of nutritional issues and dissatisfaction.
The facility did not maintain required infection control surveillance documentation for the previous year, as confirmed by the DON. A resident was treated for a UTI during this period, but no surveillance records were available to track or monitor infections as outlined in the facility's policy.
Surveyors observed that multiple resident rooms and the main dining room had significant maintenance issues, including damaged drywall, missing or broken tiles, worn furniture, and broken window blinds. Facility staff confirmed awareness of some of these problems, and incomplete repairs were noted during the inspection.
The facility failed to maintain proper food safety and sanitation practices, with unlabeled and expired food items found in storage, and a lack of temperature logs for kitchen equipment. The kitchen environment was unsanitary, with appliances and preparation areas covered in grime. Staff interviews revealed a lack of awareness and adherence to food safety protocols.
The facility failed to maintain a medication error rate below five percent, resulting in an 8.57% error rate. Three residents received incorrect dosages of medications, as confirmed by an LPN. The DON expects staff to follow physician orders and monitors compliance through audits and observations.
The facility failed to provide meals that were palatable, appetizing, and attractive, affecting 97 residents. Observations showed meals deviated from the planned menu, such as serving a meatless hotdog bun with cheese and chicken noodle soup. The Dietary Manager cited ingredient shortages as the reason for substitutions, while the Registered Dietitian noted that alternate menu choices should be available but had not verified their posting.
The facility failed to properly label and store bath basins, bedpans, and urinals in several rooms, as required by their infection control policy. Observations showed these items were not bagged or labeled, which was confirmed by staff interviews, including a CNA, an LPN, and the DON. This deficiency highlights a lapse in maintaining a sanitary environment to prevent cross-contamination.
The facility failed to assess the ability of four residents to self-administer medications, resulting in medications being left at their bedside without proper authorization. Despite the facility's policy requiring secure storage of medications, observations revealed that medications were left at the bedside for residents with various diagnoses, including lupus, Alzheimer's, and diabetes, without documented assessments for self-administration. The DON confirmed that no residents had self-administration orders, and all medications should be administered under supervision.
The facility failed to honor residents' meal preferences and provide snacks, affecting 108 residents. Residents reported not receiving snacks, cold food, and lack of assistance to the dining room. The Dietary Manager admitted to substituting meals due to menu changes, and the Registered Dietitian noted gaps in providing alternatives and missing menu cards on trays, crucial for dietary communication.
A facility failed to provide a resident and their representative with written bed hold information at the time of hospital transfer or within 24 hours, as required by policy. Despite multiple hospitalizations, there was no evidence of compliance with this requirement. Interviews with staff confirmed the oversight, and the Administrator was unaware of the lapse.
A facility failed to complete a PASARR Level 2 assessment for a resident with schizophrenia and other medical conditions, who was admitted with only a Level 1 assessment from the hospital. Despite the resident's complex needs and use of psychoactive medications, the necessary Level 2 review was not conducted. Interviews revealed that the hospital did not complete the Level 2 assessment in 2021, and the facility did not initiate it upon admission.
A resident with multiple diagnoses was discharged without proper medication reconciliation and documentation. The discharge summary lacked a complete list of medications and necessary signatures, and there was a discrepancy in the resident's code status. Interviews revealed that the resident did not receive all medications, and specific information about their functional level was missing. The LPN admitted to not making a copy of the medication form for the medical record.
The facility failed to ensure a safe environment for three residents, who were found with hazardous items like nail polish remover, isopropyl alcohol, and Hibiclens Antiseptic in their rooms. Despite efforts to declutter and inform residents about prohibited items, these hazards were present. The DON acknowledged the issue of clutter and inappropriate items in resident rooms.
The facility failed to provide effective oxygen therapy for four residents, with issues such as improper storage of equipment, lack of physician orders, and inadequate documentation. One resident with a tracheostomy had essential equipment on the floor, while another received oxygen without an order. Two other residents experienced inconsistencies in oxygen flow rates and documentation, indicating systemic issues in respiratory care management.
A facility failed to document communication between its staff and a dialysis center for a resident with end-stage renal disease. The facility's policy requires ongoing assessment and communication, but several dialysis communication forms were incomplete or missing. Interviews with staff, including an LPN and the DON, confirmed the lack of documentation, which was not addressed until highlighted during a survey.
The facility did not provide meals and snacks according to residents' needs and preferences, affecting 97 out of 112 residents. Despite a policy requiring adjustment of menus to meet individual needs, residents reported not receiving snacks at night. The Dietary Manager admitted to limiting snacks due to concerns about food going missing, and an LPN confirmed that snacks were not offered. The Administrator was unaware of the limited snack provision.
Failure to Prepare and Follow Advance Menus with Diet-Specific Modifications
Penalty
Summary
The facility failed to ensure that menus were prepared in advance and included necessary details such as serving sizes and diet-specific modifications for residents' diet orders. During the survey, the facility was unable to provide complete menu cycles and menu extensions for all diets, and the available documentation did not specify which foods were appropriate for various modified diets, including soft, bite-sized, potassium-restricted, finger food, reduced sodium, no added salt (NAS), and renal diets. Observations revealed that meals served did not always match the planned emergency menus, and handwritten instructions for meal preparation lacked information on portion sizes and diet accommodations. Staff interviews confirmed that, following a kitchen fire, the facility relied on emergency menus but did not consistently provide documentation or guidance for dietary modifications or portion sizes. Residents reported receiving meals that differed from the emergency menu, and dietary staff were observed preparing meals without clear instructions on the amount of food to serve or how to modify meals for specific diets. The Registered Dietician stated that the food service vendor provided menus and recipes for all diets, but these were not fully utilized by the dietary manager during the emergency period. The facility was unable to provide a dietary policy regarding menu preparation and documentation before the survey exit, and the lack of clear, advance menu planning and documentation placed all residents receiving oral meals at risk of nutritional problems and dissatisfaction.
Missing Infection Control Surveillance Documentation
Penalty
Summary
The facility failed to maintain infection control surveillance documentation for the year 2024, as required by its own policy. Review of the facility's Infection Surveillance policy indicated the purpose was to identify and monitor infections to reduce and prevent their spread. However, the only available surveillance documentation was for January through June 2025, with no records for 2024. This deficiency was confirmed during an interview with the DON, who was unable to provide any infection control surveillance records for 2024. Additionally, a resident was treated for a urinary tract infection in December 2024, with supporting documentation in the medical record, but there was no corresponding infection surveillance documentation for that period.
Failure to Maintain Safe and Homelike Resident Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for residents, as required by its own policy. Observations conducted across four units revealed multiple deficiencies in 13 resident rooms and the main dining room. Specific issues included gouged and marred drywall, missing or broken tiles, dark discoloration around baseboards, worn laminate on tables, splintered wood on doors, and missing or damaged window blinds. Additional findings included holes in bathroom doors, unsanded and unpainted wall patches, separated drywall seams, missing base molding, and missing drawers in closets. Interviews with the Maintenance Director and Regional Maintenance Director confirmed awareness of some of these issues, with the Maintenance Director acknowledging incomplete repairs, such as unsanded and unpainted drywall patches. The Regional Maintenance Director indicated he was new to the corporation and unaware of the extent of the repair needs. These conditions were directly observed and documented by surveyors during their inspection.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to adhere to proper food safety and sanitation practices, as observed during a kitchen tour. Several food items in the walk-in cooler and freezer were not labeled or dated, including a container of tea, shredded lettuce, cooked sausage patties, and hot dog buns. Additionally, expired food items such as yogurt and relish were found. The facility also lacked records of daily temperature logs for the freezers, cooler, dishwasher, steam table, and sanitizing solution in the three-compartment sink. This lack of monitoring and documentation could potentially affect 97 of the 112 residents receiving an oral diet. The kitchen environment was found to be unsanitary, with appliances such as the oven, fryer, and convection oven coated in grease and grime. Food preparation areas, countertops, and floors were soiled with food crumbs, dirt, and debris. The ice machine contained a black substance, and the sanitizing sink was surrounded by debris and food particles. The facility's maintenance worker confirmed that the ice machine is cleaned every three months, but there were no logs or manufacturer's cleaning recommendations available. Interviews with the Dietary Manager, Administrator, and kitchen staff revealed a lack of awareness and adherence to food safety protocols. The Dietary Manager confirmed the absence of temperature logs and acknowledged the environmental concerns in the kitchen. The day shift cook was unaware of the requirement to log steam table temperatures, and the Dietary Aid mentioned the absence of a cleaning list. The Administrator recognized the need for a deep clean of the kitchen and acknowledged the potential risk of illness from a dirty ice machine.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent during medication administration, resulting in an error rate of 8.57%. This deficiency was identified through observation, record review, and staff interviews. Three residents were involved in the medication errors. Resident 44, diagnosed with Alzheimer's Disease and urinary retention, was administered Cranberry 450mg instead of the ordered Cranberry 425mg. Similarly, Resident 46, with Type 2 Diabetes Mellitus and a history of cerebral infarction, received Cranberry 450mg instead of the prescribed Cranberry 425mg. Resident 61, who has a history of cerebral infarction and prediabetes, was given Vitamin D3 125mcg instead of the ordered Vitamin D3 25mcg. The errors were confirmed during an interview with an LPN, who acknowledged the discrepancies between the medications given and the physician's orders. The Director of Nursing (DON) expressed an expectation for staff to adhere to physician orders and indicated that her role includes monitoring staff through audits and observations to ensure compliance. Despite these expectations, the facility's failure to ensure accurate medication administration led to a medication error rate exceeding the acceptable threshold.
Deficiency in Meal Quality and Menu Adherence
Penalty
Summary
The facility failed to ensure that meals served to residents were palatable, appetizing, and attractive, affecting 97 of 112 residents on an oral diet. The facility's policy required that menus meet nutritional needs, be prepared in advance, and deviations be documented and approved by a dietitian. However, observations revealed that meals served did not adhere to these standards. For instance, a meal consisting of a meatless hotdog bun with a slice of cheese, chicken noodle soup, and a side of lettuce was deemed unacceptable by the Administrator and Regional Nurse Consultant. Interviews with the Dietary Manager (DM) and Registered Dietitian (RD) highlighted issues with menu adherence and food availability. The DM admitted to substituting menu items due to a lack of ingredients, such as using a hotdog bun instead of bread and omitting meat from salads due to a shortage of deli meats. The RD confirmed that alternate menu choices should be available and communicated to residents, but acknowledged that she had not verified if these were posted. The facility's menu was on a 30-day cycle, but frequent changes led to inconsistencies in meal offerings.
Failure to Properly Store and Label Personal Care Items
Penalty
Summary
The facility failed to ensure a safe, sanitary, and comfortable environment by not labeling and properly storing bath basins, bedpans, and urinals in eight of 49 rooms. Observations revealed that in several rooms on the 300 hall, including rooms 309, 313, 315, 402, 404, 405, 407, and 408, bath basins and bedpans were not labeled or bagged as required by the facility's policy. The policy, dated 2/12/2022, mandates that bedpans and urinals are for single resident use only, should be labeled with the resident's name, and stored in a plastic bag in the resident's bedside cabinet or drawer. Interviews with staff, including a CNA, an LPN, and the Director of Nursing, confirmed that all urinals and bath basins should be bagged and labeled to prevent cross-contamination. The CNA stated that all basins and urinals should be cleaned after each use and changed out every night. Despite these guidelines, the observations indicated a failure to comply with the policy, leading to a deficiency in infection prevention and control within the facility.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to assess the ability of four residents to self-administer medications before leaving medications at their bedside, contrary to the facility's policy on medication storage. The policy mandates that all medications should be stored securely and not left at the bedside unless a clinical assessment deems it appropriate for self-administration. However, observations revealed that medications were left at the bedside for residents R56, R44, R41, and R21 without documented assessments for self-administration. Resident R56, diagnosed with lupus erythematosus, asthma, and other conditions, had several medications, including Trelegy Ellipta Inhaler and Zinc Oxide Ointment, left at the bedside. The Director of Nursing (DON) and the Infection Control Nurse confirmed the presence of these medications, which were not supposed to be there. Similarly, Resident R44, with Alzheimer's Disease and other diagnoses, had Triamcinolone cream at the bedside, which was discontinued earlier in the year. The LPN confirmed the presence of the discontinued medication but was unaware of who left it there. Resident R41, who was cognitively intact, had nasal spray and eye drops at the bedside without an order for self-administration. The LPN confirmed that these medications should not have been left at the bedside. Resident R21, with a BIMS score indicating no cognitive impairment, had diclofenac sodium gel at the bedside without an order for self-administration. The DON confirmed that no residents in the facility had self-administration orders, and all medications should be administered under supervision, ensuring residents take their medications before staff leave the room.
Failure to Honor Resident Meal Preferences and Provide Snacks
Penalty
Summary
The facility failed to honor residents' rights to make choices related to meals and snacks, affecting 108 of 112 residents who can consume meals. The facility's policy stated that the residents' council would be included in menu planning, and alternatives would be provided if a food group was missing from a resident's diet. However, a review of the last six months of resident council meeting minutes revealed complaints about not receiving snacks, cold food, and lack of assistance to the dining room. Observations confirmed that no residents were in the dining room for dinner, and interviews with residents indicated that they were not informed about snack availability and that meal preferences were not honored. Interviews with the Dietary Manager and Registered Dietitian highlighted issues with menu management and communication. The Dietary Manager admitted to substituting meals due to constant menu changes and advised not to rely on the distributed menu. The Registered Dietitian acknowledged gaps in providing alternatives and noted the absence of menu cards on trays, which are crucial for communicating dietary preferences and allergies. These deficiencies in meal service and communication contributed to the failure to support resident choice and self-determination regarding meals and snacks.
Failure to Provide Bed Hold Information
Penalty
Summary
The facility failed to provide written bed hold information to a resident and their representative at the time of transfer to the hospital or within 24 hours, as required by their policy. This deficiency was identified for one resident, R154, out of three sampled residents. The facility's Bed Hold Policy, dated 2/12/22, mandates that written notice specifying the duration of the bed-hold policy and information about the resident's return to the next available bed be provided at the time of transfer for hospitalization or therapeutic leave. However, a review of the clinical and financial records revealed no evidence that such information was provided to the resident or their responsible party during multiple hospitalizations. Interviews with facility staff, including the Business Office Manager and an LPN, confirmed that the responsibility for providing the bed hold form lies with the business office manager and licensed nursing staff. The Business Office Manager admitted to not having any electronic or hard copy documentation to show that the bed hold information was provided during the hospitalizations. The Administrator was also unaware that the forms were not being given, despite expecting the staff to provide them. This lack of documentation and communication led to the deficiency being cited by the surveyors.
Failure to Complete PASARR Level 2 Assessment
Penalty
Summary
The facility failed to identify and submit a Preadmission Screening/Resident Review (PASARR) Level 2 review for a resident with a primary diagnosis of serious mental illness, developmental disability, or a related condition. The resident, who has schizophrenia and other medical diagnoses such as hemiplegia and generalized anxiety disorder, was admitted to the facility with only a PASARR Level 1 assessment completed by the hospital. Despite the resident's complex medical and psychiatric needs, including the use of multiple psychoactive medications, the necessary Level 2 assessment was not conducted upon admission. Interviews with facility staff, including the Social Service Director and the administrator, revealed that the PASARR Level 2 was not completed by the hospital in 2021, and the facility did not initiate it upon the resident's admission. The Social Service Director acknowledged that the hospital typically initiates both Levels 1 and 2, but if not, the facility should take responsibility. However, the Level 2 assessment was overlooked, and the Social Service Director was unsure why it was not initiated, as the resident was admitted before her tenure.
Deficiency in Medication Reconciliation and Documentation at Discharge
Penalty
Summary
The facility failed to properly reconcile and document the medications for a resident at the time of discharge, leading to a deficiency in the discharge process. The resident, who had diagnoses including vascular dementia, Parkinson's disease, and type 2 diabetes mellitus, was discharged without a complete and accurate discharge summary. The discharge summary did not list the medications, nor did it include the necessary signatures from the staff and the resident or their family, which are required to confirm that the medications were provided. Additionally, there was a discrepancy in the resident's code status, as the discharge summary incorrectly listed the resident as a full code, while the medical record indicated a Do Not Resuscitate (DNR) status. Interviews with the family and staff revealed that the resident did not receive all prescribed medications upon discharge, and there was a lack of specific information regarding the resident's capabilities and functional level. The Social Service Worker acknowledged the mistake in the code status, and the Director of Nursing confirmed that the discharge summary should have included care instructions, functional level, and medication documentation. The LPN involved admitted to not making a copy of the medication form with the necessary signatures for the resident's medical record, leaving the facility without proof that the medications were given to the resident or their family.
Facility Fails to Prevent Accident Hazards in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards for three residents. Resident 41, who has a history of major depressive disorder, hoarding disorder, and uses a wheelchair, was observed with nail polish remover on their bedside table. The Licensed Practical Nurse (LPN) acknowledged the presence of hazardous items and noted that some rooms have clutter, despite efforts to declutter and inform residents about prohibited items. Resident 9, who is alert and oriented with a history of heart failure and chronic kidney disease, was found with a bottle of isopropyl alcohol on their bedside table. The resident stated they purchased it themselves, and the LPN confirmed its presence, noting that residents and families are informed about restricted items. Resident 24, with hemiplegia and paranoid schizophrenia, had four bottles of Hibiclens Antiseptic on their bedside table. The resident received the bottles from another resident and was educated by a Certified Nursing Assistant (CNA) about not keeping certain chemicals. The Director of Nursing (DON) confirmed awareness of clutter and inappropriate items in residents' rooms.
Deficiencies in Oxygen Therapy Administration
Penalty
Summary
The facility failed to provide effective oxygen therapy for four residents, as observed through various deficiencies in the administration and management of respiratory care. For one resident with a tracheostomy and chronic respiratory failure, essential equipment such as an Ambu bag and suction device were found on the floor, and respiratory tubing was improperly stored, indicating a lack of adherence to infection control measures. This resident's care plan included specific orders for tracheostomy care and oxygen therapy, yet the observed conditions did not align with these requirements. Another resident, who was dependent on supplemental oxygen due to chronic respiratory failure and other conditions, was observed receiving oxygen therapy without a physician's order. Despite being on hospice care and having a care plan that highlighted the need for oxygen, the resident's oxygen therapy was not documented in the Medication Administration Record (MAR), and staff interviews confirmed the absence of an official order. This lack of documentation and oversight suggests a failure in maintaining proper records and ensuring physician-directed care. For two additional residents, discrepancies were noted in the administration of oxygen therapy. One resident had a PRN order for oxygen, but observations revealed inconsistencies in the oxygen flow rate and improper storage of equipment, such as dirty filters and unbagged tubing. Another resident was receiving continuous oxygen therapy without a physician's order or documentation in the MAR, and the care plan lacked any mention of oxygen therapy. Interviews with nursing staff and the Director of Nursing confirmed these oversights, highlighting a systemic issue in the facility's management of respiratory care.
Failure to Document Dialysis Communication for Resident
Penalty
Summary
The facility failed to ensure proper communication and documentation between its staff and the dialysis center for a resident receiving dialysis. The facility's policy on hemodialysis requires ongoing assessment and communication with the dialysis center, including monitoring the resident's condition before, during, and after dialysis treatments. However, the review of the resident's medical records revealed missing dialysis communication forms for several dates, indicating a lack of documentation of vital signs, assessment of the dialysis access site, and other necessary information. Interviews with facility staff, including an LPN and the Director of Nursing (DON), confirmed that the forms were incomplete and not properly uploaded into the electronic medical records system. The resident in question had a history of hypertensive chronic kidney disease, end-stage renal disease, legal blindness, and cerebellar stroke syndrome. Despite physician orders for dialysis on specific days, the facility failed to document the necessary information on the dialysis communication forms. The DON acknowledged that the forms were not being completed as required by policy and was unaware of the issue until it was highlighted during the survey. The lack of documentation and communication could potentially impact the resident's care and treatment, as the facility did not ensure that the necessary information was communicated to and from the dialysis center.
Failure to Provide Snacks According to Resident Preferences
Penalty
Summary
The facility failed to ensure that meals and snacks were served according to the residents' needs, preferences, and requests, as required by their policy. The policy, dated April 2024, stated that menus and available snacks should be adjusted to meet individual caloric and nutrient-intake needs. However, during a Resident Council meeting, residents expressed concerns about not receiving snacks at night. Observations revealed that the pantry contained only a limited selection of snacks, such as chocolate sandwich cookies, graham crackers, and chocolate wafer bars. The Dietary Manager admitted to providing only a limited number of snacks due to concerns about food going missing at night and confirmed the lack of ingredients to prepare sandwiches. Interviews with staff further highlighted the deficiency. The Administrator was aware of the issue of food going missing but was unaware of the limited snack provision. An LPN stated that snacks were not offered to residents, and only some received a snack bag. This deficiency affected 97 out of 112 residents, as they were not provided with nourishing alternative snacks at non-traditional times or outside of scheduled mealtimes, contrary to the facility's policy and the residents' expressed needs.
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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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