Harmony Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Fitzgerald, Georgia.
- Location
- 176 Lincoln Ave, Fitzgerald, Georgia 31750
- CMS Provider Number
- 115654
- Inspections on file
- 26
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Harmony Health And Rehabilitation during CMS and state inspections, most recent first.
A facility failed to provide timely SNFABN/NOMC notices for two residents receiving skilled therapy. In both cases, the ABN was signed after therapy had already ended, while the residents remained in the facility. The SSD said she completed the forms but did not know the required timeframe and did not have a policy for the NOMC/ABN process.
Failure to provide required transfer and bed-hold notices: A resident with intact cognition, osteomyelitis, and an amputation was sent from a vascular appointment to the hospital and later returned to the facility. Staff reported that bed-hold forms were handled informally, the BOM was not notified of written transfer notices, and the ombudsman was not notified of hospital transfers. The Administrator was unsure about written transfer notices with appeal rights and ombudsman contact information, and the facility policy required written bed-hold information within 24 hours of an emergency transfer.
Failure to complete baseline care plans for two newly admitted residents. One resident’s EMR showed admission documentation but no baseline care plan in the Evaluation tab, and staff including the MDSC, Administrator, and an LPN confirmed it was not done. The second resident had diagnoses including DM, weakness, dementia, MDD, and HTN, with diet and code status orders documented, but no evidence the baseline care plan was developed, provided, or reviewed; the MDSC, DON, and UM2 confirmed it had not been completed.
A resident with ESRD and scheduled hemodialysis had incomplete dialysis coordination and documentation. The facility record lacked orders for dialysis site or pre-/post-dialysis assessments, and dialysis communication forms were often incomplete, with missing pre-dialysis information, weights, fluid removal, and vital signs. Staff also reported difficulty obtaining information from the dialysis center, and the administrator stated there was no formal contract or agreement with the dialysis provider.
A resident with hemiplegia, contractures, seizures, and dementia—requiring two-person assist for all ADLs—sustained fractures after falling from bed during incontinent care provided by only one CNA, contrary to the care plan. The care plan interventions for fall prevention were not followed, and staff interviews confirmed care plans were not consistently updated or adhered to.
A resident with significant physical and cognitive impairments, requiring two-person assist for all ADLs and transfers, was left unattended by a CNA during incontinent care. The resident rolled out of bed and sustained fractures to the left femur and right tibia. Staff interviews and documentation confirmed the resident's need for two-person assistance was clearly indicated in the care plan and electronic records, but this protocol was not followed, resulting in actual harm.
The facility did not ensure that wound care treatments were accurately documented for three residents with pressure ulcers, resulting in multiple missed entries on the Treatment Administration Record despite physician orders and facility policy requiring timely documentation. The DON confirmed that nurses performed the treatments but failed to record them, leading to incomplete medical records.
The facility failed to maintain the ice machine in a sanitary condition, as a black substance was found inside during an inspection. Additionally, two dietary staff members were observed without hairnets in the kitchen, despite being aware of the requirement. The facility's policy on cleaning and staff head covering was not adequately enforced.
The facility failed to implement a comprehensive infection prevention training program for staff, as outlined in their policy. The DON could not provide documentation of in-service training, and an LPN showed confusion about Enhanced Barrier Precautions, indicating a lack of understanding of infection control measures. This deficiency could increase the risk of healthcare-associated infections.
A resident with a long history of smoking was denied the right to smoke by the Interim DON due to health concerns, without a physician's order or updated care plan. Despite having little cognitive impairment, the resident was not allowed to attend smoke breaks, causing distress. The facility's policy emphasizes respecting residents' autonomy, including their choice to smoke.
The facility failed to follow care plans for three residents, leading to deficiencies in oxygen therapy and catheter management. One resident received oxygen at a higher flow rate than prescribed, while another's catheter drainage bag was placed on the floor without care plan documentation. A third resident adjusted their oxygen flow rate without this behavior being care planned. Staff confirmed these discrepancies, indicating lapses in adhering to and updating care plans.
A facility failed to ensure proper administration of inhaled medication for a resident with COPD and pneumonia. An RN administered a Trelegy inhaler without instructing the resident to rinse their mouth afterward, contrary to the DON's expectations. The facility lacked a policy for inhaled medication administration, contributing to this deficiency.
A resident with COPD and pneumonia was observed receiving oxygen at three liters per minute, contrary to the physician's order of two liters per minute. This discrepancy was confirmed by an LPN, who acknowledged the incorrect setting. The facility's policy requires verification of physician orders, which was not followed, potentially putting the resident at risk.
The facility failed to follow infection control practices during medication administration and catheter management for two residents. An LPN did not perform hand hygiene during medication administration, and another LPN handled medication with bare hands and did not sanitize between glove changes. A resident's catheter bag was found on the floor, contrary to infection control protocols. Additionally, the facility's infection control policies had not been reviewed annually as required.
A resident with a history of wandering and multiple behavioral health diagnoses eloped from a secure unit and was found outside the facility. Despite facility policy requiring notification, staff interviews and record review showed that neither the physician nor the responsible party were informed of the incident, and no documentation of such notification was found.
A resident with a history of wandering and multiple behavioral health diagnoses eloped from the facility, but the care plan was not updated to reflect this incident. Although several staff members were aware of the event and documentation confirmed the resident exited through a non-secure door, the MDS Coordinator did not revise the care plan due to being unaware of the elopement.
A resident with severe cognitive impairment and a history of wandering was able to exit the facility unsupervised through a side door, despite being assessed as at risk for elopement and assigned to a secure unit. Staff interviews and maintenance records revealed lapses in supervision and door security, as well as confusion among staff regarding the resident's location and the events leading up to the elopement.
Late SNFABN Notices for Two Residents
Penalty
Summary
The facility failed to provide Form CMS-10055, Skilled Nursing Facility Advance Beneficiary Notice (SNFABN), in a timely manner for two residents reviewed for liability notices. For one resident, the record showed skilled therapy services were scheduled to end on 12/10/2025, but the SNF ABN was signed on 12/22/2025, 11 days after therapy services ended. The resident remained in the facility after the end of skilled therapy services, and the Administrator stated the resident still had skilled benefit days remaining. For the second resident, the record showed skilled services ended on 12/18/2025, but the SNF ABN was signed on 12/22/2025, 4 days after therapy services ended. This resident also remained in the facility after the end of skilled therapy services. The Social Services Director stated she completed the SNFABN documents but was not aware of a specific time frame for completion and did not have a policy and procedure for the NOMC/ABN. The Therapy Director stated she informed the team during morning meetings when a resident would be coming off therapy services and that the Social Worker was given the information three days prior to therapy ending.
Failure to Provide Transfer and Bed-Hold Notices
Penalty
Summary
The facility failed to notify the ombudsman and failed to provide a resident and the resident's representative with the required written transfer and bed-hold notices after an emergency hospital transfer for R87. R87 was originally admitted to the facility and later readmitted, with diagnoses including osteomyelitis and acquired absence of the left foot. The quarterly MDS with an ARD of 01/21/26 showed a BIMS score of 15 out of 15, indicating intact cognition. Progress notes documented that R87 was out of the facility for a vascular appointment on 02/02/2026 and was admitted to the hospital the same day, then returned to the facility on 02/13/2026 via stretcher. Interviews showed that the Social Services Director had no role in providing bed-hold or written transfer notices. The Business Office Manager stated nurses completed bed-hold forms when residents were sent to the hospital and placed copies under her door, but she was unaware of any written transfer notice and did not notify the ombudsman of transfers or discharges. An LPN confirmed that when a resident was transferred to the hospital, information including a bed-hold notice was sent with the resident and a copy was placed under the BOM's door. The Administrator stated residents were given a bed-hold policy when leaving, was unsure about any written notice of transfer that included appeal rights and ombudsman contact information, and did not have a policy for that notice. The facility policy titled Bed Hold Notice Upon Transfer stated that before transfer to the hospital or therapeutic leave, the resident and/or representative would be provided written information about bed-hold and reserve bed payment policies, and that in an emergency transfer the facility would provide written notice of its bed-hold policies within 24 hours.
Failure to Complete Baseline Care Plans for Two Newly Admitted Residents
Penalty
Summary
The facility failed to complete a baseline care plan for two of 27 sampled residents, R85 and R29. Review of R85’s EMR showed an admission date of 10/31/2025, but there was no documentation in the Evaluation tab that the baseline care plan had been completed. During interview, the MDSC stated that it is the nurse’s responsibility to complete the baseline care plan at the time of admission and said it did not appear to have been done for R85. The Administrator also confirmed that R85’s baseline care plan was not done and stated that the care plan would be located in the EMR under the Evaluation tab. The Administrator further stated the facility did not have a policy for baseline care plans, and an LPN stated she did not know about doing a baseline care plan at the time of admission and that the charge nurse only completes the Nursing Admission/readmission Evaluation document. Review of R29’s EMR showed admission with diagnoses of diabetes mellitus, muscle weakness, dementia, major depressive disorder, and hypertension. Physician orders included a regular diet, mechanical soft with chopped meats texture, thin liquids, and full code status. The EMR contained no documentation that a baseline care plan was developed upon admission or that it was generated, provided, or reviewed with R29 or the resident’s representative. The MDSC stated the baseline care plan is conducted by the unit nurse and confirmed it had not been completed for R29. The DON stated that when a resident is admitted, the admission assessment is completed by the nurse and an initial baseline care plan is generated, but said there was miscommunication and the baseline care plan for R29 was not completed. UM2 also confirmed that R29’s baseline care plan had not been completed.
Dialysis Care Not Properly Coordinated or Documented
Penalty
Summary
Safe, appropriate dialysis care/services were not provided for a resident with ESRD and dependence on renal dialysis. The resident was admitted with diagnoses of end stage renal disease and was scheduled for hemodialysis on Tuesday, Thursday, and Saturday at an outside dialysis center. The care plan included instructions not to draw blood or take blood pressure in the arm with the graft, encourage attendance at scheduled dialysis, monitor labs, and monitor vital signs, but the only related orders in the record were for Enhanced Barrier Precautions and the hemodialysis schedule. There were no orders for assessment of the dialysis site or for pre- or post-dialysis resident assessments. Review of dialysis communication forms from 01/01/2026 through 03/03/2026 showed communication on 14 of 16 dialysis treatments, but the pre-dialysis section was not filled out or was only partially filled out on 12 of 14 forms. The dialysis center information was missing weights, fluid removed, and/or vital signs on nine dates. The post-dialysis section, which included assessment of the shunt/catheter and vital signs, was completed and signed by the dialysis center on seven occasions. Staff interviews confirmed that the facility nurse was expected to complete the pre-dialysis section, that the unit manager had difficulty obtaining post-weights and often left messages that were not returned, and that the DON was unsure who was responsible for the post-assessment portion. The administrator stated the dialysis center refused to provide a contract or formal agreement with the facility.
Failure to Follow Care Plan for Fall Prevention Results in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to follow the care plan interventions related to fall prevention for a resident with significant medical and cognitive impairments. The resident had a history of hemiplegia, contractures in both knees, seizures, dementia with behavioral disturbances, and was dependent on staff for all activities of daily living (ADL), including transfers, which required assistance from two or more staff members. The care plan specifically identified the resident as being at risk for falls and required a two-person assist for ADL care due to extensive assistance needs and confusion, including delusions about being able to walk. Despite these documented needs and interventions, only one CNA provided incontinent care, during which the resident rolled out of bed and fell to the floor. As a result, the resident sustained a distal fracture of the left femur and a fracture of the lower end of the right tibia. Review of facility policy and interviews confirmed that care plans were not consistently updated or followed, and the required two-person assist was not provided at the time of the incident.
Failure to Provide Required Two-Person Assist Results in Resident Fall and Fractures
Penalty
Summary
A deficiency occurred when a resident who required a two-person assist for all activities of daily living (ADL) care and transfers was provided incontinent care by only one Certified Nursing Assistant (CNA). During this care, the resident rolled out of bed and fell to the floor, resulting in a distal fracture of the left femur and a fracture of the lower end of the right tibia. The resident's care plan and Minimum Data Set (MDS) assessment clearly indicated the need for two-person assistance due to significant physical and cognitive impairments, including hemiplegia, contractures, seizures, altered mental status, and a history of attempting to get out of bed unassisted. The facility's policy on incidents and accidents required staff to provide immediate assistance and follow established protocols to prevent accidents. However, interviews and record reviews revealed that the CNA entered the resident's room alone to provide care, contrary to the care plan and facility policy. The CNA left the resident on his side to retrieve an item from the hallway, during which time the resident continued to roll and fell from the bed. Documentation in the electronic medical record and staff interviews confirmed that the resident was dependent on staff for all ADLs and required two-person assistance for bed mobility and transfers. Further interviews with facility staff, including the Administrator, LPNs, and other CNAs, confirmed that the resident's need for two-person assistance was documented in the care plan, Kardex, and Point Click Care (PCC) system. Staff were expected to communicate changes in resident care needs during shift changes and to verify assistance requirements in the PCC system. Despite these protocols, the failure to provide adequate supervision and follow the resident's care plan directly led to the resident's fall and subsequent injuries.
Failure to Document Wound Care Treatments as Ordered
Penalty
Summary
The facility failed to ensure accurate and complete documentation of wound care treatments for three residents with pressure ulcers. For one resident with multiple chronic conditions, including congestive heart failure and peripheral vascular disease, there was no documentation on the Treatment Administration Record (TAR) for several dates when wound care was ordered. Another resident with diabetes and a chronic venous ulcer also had missing documentation on the TAR for multiple dates in both May and June, despite physician orders specifying wound care on certain days. A third resident with a history of diabetic foot ulcer and other chronic illnesses similarly had gaps in documentation for ordered wound treatments. The facility's policy required that wound treatments be documented at the time of each treatment, and if no treatment was due, the status of the dressing should be recorded each shift. However, review of the TARs showed that documentation was not consistently completed as required. The Director of Nursing confirmed that, although nurses were performing the treatments, they were not documenting them on the TARs, leading to incomplete medical records for these residents.
Deficiencies in Ice Machine Sanitation and Staff Head Covering
Penalty
Summary
The facility failed to maintain the ice machine in a clean and sanitary condition, as evidenced by the presence of a black substance on the upper inside of the machine. This was observed during an inspection in the main kitchen, where a white napkin used to wipe the area revealed the black substance. The facility's policy on cleaning the ice machine and equipment was reviewed, which outlined procedures for regular cleaning and sanitization. However, the observation indicated that these procedures were not adequately followed, as the ice machine was not maintained in a clean state. Additionally, the facility did not ensure that dietary staff wore appropriate head coverings in the food service area. During the inspection, two dietary staff members, identified as Dishwasher AA and Dishwasher BB, were observed without hairnets. Interviews with the staff confirmed that they were aware of the requirement to wear hairnets upon entering the kitchen but failed to do so. The Dietary Manager also confirmed that staff had been in-serviced about wearing hairnets and that hairnets were available outside the kitchen. This oversight in enforcing the use of hairnets further contributed to the facility's failure to adhere to professional standards in food service areas.
Deficiency in Infection Prevention Training Program
Penalty
Summary
The facility failed to establish, implement, and sustain a comprehensive training program for all staff, which included education on standards, policies, and procedures for infection prevention. The facility's policy titled 'Annual Inservice Education for Long Term Care 2024' outlined an annual education calendar that was supposed to be implemented each year, covering various topics including infection control and prevention. However, the facility was unable to provide documentation of in-service training provided to staff, indicating a lapse in the execution of the training program. During the survey, the Director of Nursing (DON) admitted to being unable to locate any records of in-service education provided by the previous DON. Additionally, an LPN expressed confusion about Enhanced Barrier Precautions (EBP) during an interview, revealing a lack of understanding of the difference between EBP and Transmission-Based Precautions (TBP). The LPN was also unsure about the documentation process for this information in the resident's chart. This lack of training and understanding among staff had the potential to increase the risk of healthcare-associated infections and compromise the quality of care provided to the residents.
Resident's Right to Smoke Denied Without Proper Assessment
Penalty
Summary
The facility failed to honor a resident's right to self-determination and dignity by not allowing them to exercise their right to smoke. The resident, who had a history of smoking a pack a day for over 50 years, was restricted from smoking by the Interim Director of Nursing (DON) due to health concerns such as pneumonia, coughing, and lips turning blue. However, this decision was made without a physician's order, an updated care plan, or a completed smoking assessment indicating that the resident was ineligible to smoke. The facility's policy on Resident Rights and Dignity Management emphasizes the importance of respecting residents' autonomy, including their choice to smoke. The resident, identified as having schizoaffective disorder bipolar, chronic obstructive pulmonary disease, and emphysema, had a Brief Interview for Mental Status (BIMS) score indicating little to no cognitive impairment. Despite this, the resident was not allowed to attend the designated smoke break, which was confirmed through observation and interviews. The Nurse Practitioner noted that the resident should have been informed about the potential health risks of smoking but still allowed to make their own decision. The resident expressed that the restriction on smoking was causing more harm than good, as it significantly reduced their smoking from three to four cigarettes per day to none.
Failure to Follow Care Plans for Oxygen Therapy and Catheter Management
Penalty
Summary
The facility failed to ensure that the care plan was followed for three residents, leading to deficiencies in their care. For one resident with chronic obstructive pulmonary disease (COPD) and pneumonia, the care plan required oxygen therapy at 2 liters per minute via nasal cannula. However, observations revealed that the oxygen was being delivered at 3 liters per minute, contrary to the physician's order. This discrepancy was confirmed by a Licensed Practical Nurse (LPN) and the Unit Manager, who acknowledged that the care plan was not being adhered to. Another resident with neuromuscular dysfunction of the bladder and other conditions had an indwelling catheter. The care plan did not address the placement of the catheter drainage bag, which was observed lying on the floor during multiple visits. An LPN confirmed that the bag was placed on the floor to facilitate drainage, but this practice was not included in the care plan. The Director of Nursing (DON) acknowledged that this situation needed to be care planned, indicating a lapse in updating the care plan to reflect the resident's needs. The third resident, diagnosed with COPD and chronic respiratory failure, was observed receiving oxygen at a higher flow rate than prescribed. The resident adjusted the oxygen flow rate himself, setting it at 4 liters per minute instead of the ordered 2 liters. An LPN confirmed that the resident had been educated about the risks of adjusting the oxygen flow, but the behavior was not care planned. The MDS Coordinator and DON both acknowledged that the resident's behavior should have been included in the care plan, highlighting a failure to document and address the resident's actions in the care plan.
Failure to Ensure Proper Administration of Inhaled Medication
Penalty
Summary
The facility failed to ensure proper administration of inhaled respiratory medication for a resident diagnosed with chronic obstructive pulmonary disease (COPD) and pneumonia. During an observation, a Registered Nurse (RN) prepared and administered a Trelegy inhaler to the resident without instructing them to rinse their mouth afterward, which is a standard practice to prevent potential side effects. The RN confirmed in an interview that she does not typically instruct residents to rinse their mouths after using inhalers, although some staff do. The facility did not provide a policy for administering inhaled medications when requested. The Director of Nurses (DON) stated that it is her expectation for residents to rinse their mouths after receiving inhaled medications. The resident's care plan included administering aerosol or bronchodilators as ordered and monitoring for side effects, but the lack of mouth rinsing was not addressed. This oversight in following proper medication administration procedures was identified as a deficiency during the survey.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to administer oxygen therapy to a resident, identified as R24, in accordance with the physician's orders. R24, who was admitted with diagnoses including chronic obstructive pulmonary disease (COPD) and pneumonia, was observed receiving oxygen at a rate of three liters per minute via nasal cannula, despite the physician's order specifying two liters per minute as needed for shortness of breath. This discrepancy was confirmed by a Licensed Practical Nurse (LPN) during an observation and interview, who acknowledged that the oxygen concentrator was set incorrectly. The facility's policy on Respiratory System Management requires verification of the physician's order in the resident's clinical record, which was not adhered to in this case. The resident's care plan, which included monitoring for signs of acute respiratory insufficiency and ensuring oxygen settings as ordered, was not followed. Interviews with the LPN and the Unit Manager confirmed that it is the responsibility of the nursing staff to ensure compliance with physician orders and care plans, which was not done in this instance, potentially putting the resident at risk for medical complications.
Infection Control Deficiencies in Medication Administration and Catheter Management
Penalty
Summary
The facility failed to adhere to proper infection control practices during medication administration for two residents. During an observation, an LPN did not perform hand hygiene before or after preparing and administering medications to a resident with acute and chronic respiratory failure and neuromuscular dysfunction of the bladder. The LPN admitted to not following the hand hygiene protocol. In another instance, a different LPN handled a medication capsule with bare hands and failed to perform hand hygiene between glove changes during medication administration. The facility also failed to ensure proper management of an indwelling catheter for a resident with neuromuscular dysfunction of the bladder, colostomy malfunction, and chronic viral hepatitis C. Observations revealed that the resident's catheter bag was repeatedly found lying on the floor, which was confirmed by an LPN who stated that it was necessary for drainage. The Director of Nurses acknowledged that a catheter bag should never be on the floor and should be placed on a barrier if necessary. Additionally, the facility did not review its infection control policies and procedures annually as required. The Infection Control Manual had not been updated for over a year, with the last revision dated September 2023. The Director of Nurses confirmed the oversight and indicated that the facility would begin updating the policies and procedures.
Failure to Notify Physician and Responsible Party After Resident Elopement
Penalty
Summary
The facility failed to notify the physician and responsible party following an elopement incident involving a resident with a history of wandering and elopement risk. The facility's own Elopement Management policy required that, after an elopement, a progress note be completed in the clinical record with an accurate timeline of events and that both the medical doctor and responsible party be notified and documentation of this notification be made. Review of the clinical record for the resident, who had diagnoses including schizoaffective disorder, traumatic brain injury, post-traumatic stress disorder, and unsteadiness on feet, revealed no evidence that such notifications were made after the resident left the secure unit and exited the facility. Staff interviews confirmed that the resident was found outside the facility and returned to the secure unit, but staff could not recall the exact date of the incident. One LPN stated she found the resident outside and returned him to the secure unit, while another LPN, who was working on the secure unit at the time, was unaware of the incident and did not notify the physician or responsible party. A CNA also recalled the resident leaving the facility but did not provide further details regarding notification. Documentation, including a maintenance request, confirmed the resident exited through a side door, but there was no record of required notifications being made.
Failure to Update Care Plan After Resident Elopement
Penalty
Summary
The facility failed to revise and update the care plan for one resident following an elopement event. The resident, who had diagnoses including schizoaffective disorder, traumatic brain injury, post-traumatic stress disorder, and unsteadiness on feet, was assessed as exhibiting wandering behavior and was independent in mobility and ambulation. The resident's care plan, initiated previously, identified a risk for elopement and included placement on a secure unit. However, after the resident eloped from the facility, there was no evidence that the care plan was updated to reflect this incident, as required by the facility's Elopement Standard and Task List. Staff interviews revealed that multiple staff members were aware of the resident's elopement, with one LPN finding the resident outside and a CNA recalling the incident. Despite this, the MDS Coordinator confirmed she was unaware of the elopement at the time, which resulted in the care plan not being revised. Documentation, including a maintenance request, confirmed the resident exited through a side door not associated with the secure unit. The lack of care plan revision following the elopement constituted the identified deficiency.
Failure to Prevent Elopement Due to Inadequate Supervision and Door Security
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and secure the environment to prevent elopement for a resident with severe cognitive impairment and a history of wandering. The resident, who had diagnoses including schizoaffective disorder, traumatic brain injury, post-traumatic stress disorder, and unsteadiness on feet, was assessed as being at risk for elopement and was supposed to reside on a secure unit. Despite these precautions, the resident was able to exit the facility through a side door on the North Hall, which was not the secure unit assigned at the time. Staff interviews and maintenance records confirmed that the resident was found outside the facility and brought back inside, with uncertainty about how the resident exited and which unit the resident was residing on at the time. The facility's Elopement Standard required accurate documentation and supervision for residents at risk of elopement, but the incident revealed lapses in both supervision and door security. Maintenance logs showed the door had been checked and passed prior to the incident, but the resident was still able to exit. Staff accounts indicated confusion regarding the resident's whereabouts and the timeline of events, and there was a lack of clarity about which staff were responsible for the resident's supervision at the time of the elopement. The failure to secure the door and provide adequate supervision directly led to the resident's unsupervised exit from the facility.
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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