Hazelhurst Court Care And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Hazlehurst, Georgia.
- Location
- 180 Burkett Ferry Road, Hazlehurst, Georgia 31539
- CMS Provider Number
- 115626
- Inspections on file
- 21
- Latest survey
- March 29, 2026
- Citations (last 12 mo.)
- 14 (3 serious)
Citation history
Health deficiencies cited at Hazelhurst Court Care And Rehabilitation Center during CMS and state inspections, most recent first.
Food items were found improperly labeled, undated, and in some cases expired during a kitchen tour with the Dietary Mgr. Surveyors observed opened and unlabeled frozen items, undated pantry items, and multiple opened prep-station items that lacked open dates or had expired dates. The Dietary Mgr confirmed all findings and stated she was responsible for ensuring food was labeled with open and expiration dates.
Uncleaned Dryer Lint Trap: During an observation, the lint filter of the second dryer near the window was found not cleaned. The ESD stated lint traps must be cleaned after each use or at least every hour with documentation, and confirmed the dryer lint trap had not been cleaned per facility policy. The ESD also stated that unclean lint filters could cause a fire.
A facility failed to notify a resident and/or her representative when trust fund balances were within $200 of the SSI limit and when the account exceeded the $2,000 cap. The resident had severe cognitive impairment with a BIMS of 5 and diagnoses including dementia, while staff interviews showed the VP of Revenue Cycle Management, receptionist, and Social Services did not ensure written financial notices were sent to the family representative, who said she never received any financial statements or notices.
A facility failed to follow care plans for two residents. One resident with diabetes, reduced mobility, and personal care needs had long, untrimmed fingernails with debris under the nail beds despite a care plan directing nail care on scheduled bath days. Another resident with acute chronic respiratory failure with hypoxia had a physician order for O2 at 2 L/min via NC, but the care plan and staff interview showed the setting was incorrect.
Failure to Provide Nail Care for a Resident Needing ADL Assistance: A resident with type 1 DM, reduced mobility, and dependence on staff for ADLs was observed with long, untrimmed fingernails and visible brown debris under the nail beds. The resident was scheduled for bath days, had no documented refusal of hygiene care, and staff including a CNA, LPN, DON, and RN UM confirmed the nail condition and that nurses and CNAs were responsible for nail care, with nurses trimming nails for residents with diabetes.
A resident with acute chronic respiratory failure with hypoxia, SOB, and oxygen therapy orders was observed receiving oxygen via nasal cannula at 1.5 LPM instead of the ordered 2 LPM. The DON confirmed nurses were responsible for checking the setting during med pass and rounding, and later stated the concentrator was faulty and the rate was off by a half liter.
A resident with multiple medical conditions and a documented Full Code status was not provided CPR when found unresponsive, despite clear physician orders and care plan directives. Nursing staff did not attempt resuscitation, mistakenly believing that hospice admission changed the code status to DNR, even though the POLST and care plan specified Full Code. This deficiency was confirmed during staff interviews and record review.
A resident with full code status and clear physician orders to attempt CPR was found unresponsive and not breathing. Despite facility policy and documentation specifying to initiate CPR, staff did not attempt resuscitation, mistakenly believing that hospice enrollment implied DNR status. Multiple staff, including LPNs and CNAs, failed to verify the resident's code status or provide life-sustaining measures, resulting in the deficiency.
Nursing administration did not ensure that staff followed a resident's Full Code advance directive, resulting in no CPR being attempted when the resident was found unresponsive. Despite clear documentation and confirmation from the responsible party that the resident was to remain Full Code, staff incorrectly assumed hospice status meant DNR, leading to the deficiency.
The facility failed to provide residents with appealing meal options, offering only sandwiches or soup as alternatives if residents disliked the meal served. During a Resident Council meeting, residents expressed dissatisfaction with the lack of alternate meal choices. The facility's menu did not include alternate meal options, and staff interviews confirmed the absence of hot entrees as alternatives. A resident reported never having a choice of meals, and observations confirmed the lack of alternate meals during service. The Administrator acknowledged the issue but stated that residents could receive a grilled cheese sandwich if requested.
The facility did not follow its food storage policy, resulting in expired food items being found in the stand-up cooler during a kitchen tour. The Dietary Manager confirmed and discarded the expired sliced ham and chicken and noodles, acknowledging the expectation for staff to dispose of items before expiration. This oversight potentially affected 50 of 53 residents on an oral diet, posing a risk of illness.
A facility failed to follow infection control protocols during tracheostomy care for a resident with multiple diagnoses, including tracheostomy status. RN AA did not perform hand hygiene after glove changes, and soiled items were improperly disposed of, increasing the risk of infection. Staff interviews revealed a lack of in-service training for LPN CC, and the DON confirmed expectations for proper hand hygiene and glove changes.
The facility failed to maintain a clean environment in a resident's room, as a privacy curtain was found with a brown stain and white chalky substance. Despite the facility's policy for monthly deep cleaning, Room 33 was not cleaned in January or February 2025. Interviews revealed that the housekeeper did not notice the soiled curtain, and the Administrator confirmed the expectation for staff to follow cleaning protocols.
A facility failed to provide a written reason for transfer to a resident or their representative, as required by policy. Despite the policy mandating written notification, staff interviews revealed that the facility only provided verbal communication. This inconsistency with policy led to a deficiency being identified during the survey.
A facility failed to provide a written bed hold notice to a resident's representative during hospital transfers, contrary to its policy. Despite the policy requiring written notification within 24 hours of an emergency transfer, staff interviews revealed that the facility only verbally informed the representative, assuming the resident would return. An unsigned bed hold agreement was found in the resident's record.
The facility failed to follow care plans for oxygen administration for three residents, leading to discrepancies between physician orders and actual care provided. One resident with COPD received oxygen at a higher rate than ordered, while another with acute respiratory failure did not receive the prescribed oxygen via trach collar. The MDS Coordinator and DON confirmed these failures, highlighting a lack of adherence to the facility's care planning policy.
The facility failed to follow physician orders for oxygen administration for three residents, leading to incorrect oxygen flow rates. A resident with COPD received 7 liters per minute instead of 3, another with COPD received 3 liters instead of 2, and a resident with acute respiratory failure received 5 liters instead of 4. LPNs admitted to not checking the oxygen settings during medication pass, contrary to the DON's expectations.
Food Items Left Open, Undated, and Expired
Penalty
Summary
The facility failed to ensure food was properly labeled, dated, and maintained in sanitary conditions in accordance with the policy titled Food Storage. During a tour with the Dietary Manager, surveyors observed multiple food items in the freezer that were opened and not labeled, including a large bag of broccoli and a box of frozen cinnamon rolls, along with two packs of dumplings and a pack of spinach that were past the expiration date. In the pantry, four boxes of lasagna and one gallon jug of Worcestershire sauce were not dated. In the kitchen at one of the prep stations, surveyors observed five opened seasoning containers, pancake and waffle syrup, two cans of cooking spray, a gallon bottle of barbeque sauce, two bottles of lemon juice, a bag of brownie mix with an expired date, a bag of corn meal mix, a container of salt with an expired date, and a jar of mayonnaise that were opened and/or not dated. The Dietary Manager confirmed all of the surveyor's identified concerns and stated she was responsible for ensuring food was labeled with open and expiration dates.
Uncleaned Dryer Lint Trap
Penalty
Summary
The facility failed to ensure adherence to established laundry maintenance protocols related to dryer lint trap cleaning. During an observation on 03/28/2026 at 8:40 AM, the lint filter of the second dryer located near the window was observed not to have been cleaned. During an interview on 03/28/2026 at 10:52 AM, the Environmental Services Director stated that lint traps are required to be cleaned after each use or, at a minimum, every hour, with staff required to document completion, and confirmed that the lint trap in the second dryer had not been cleaned in accordance with facility policy. The Environmental Services Director also confirmed that if the lint filters are not cleaned it could cause a fire.
Failure to Notify Resident and Representative of Trust Fund Balance Limits
Penalty
Summary
The facility failed to notify the resident and/or the resident’s responsible party when personal funds were within $200 of the SSI limit and when the account balance exceeded the allowable amount. Facility policy titled Resident Trust Fund stated that Medicaid recipients must be notified whenever their funds are within $200 of their resource asset limit and that balances should be monitored monthly to ensure state maximum balances are not exceeded. Review of the Resident Statement Landscape report showed that R45’s trust fund accounts exceeded the $2,000 SSI limit for 12 months, from February 2025 through February 2026. R45’s record showed diagnoses including dementia in other diseases classified elsewhere, severe without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, cognitive communication deficit, and dementia, mild, with agitation. The quarterly MDS documented a BIMS score of 5, indicating severe cognitive impairment. Interviews revealed the VP of Revenue Cycle Management was handling resident accounts after the BOM position was vacant and admitted she had not followed up with the Medicaid Eligibility Officer about R45’s account being over $2,000 for the last 12 months. The receptionist stated she was responsible for notifying residents and/or representatives when accounts reached within $200 of $2,000, but she had not sent written notifications to R45’s representative since June 2025 and had only given notices to R45. R45’s family representative stated she had never received any financial notices or statements from the facility, and Social Services stated she contacted the representative about spending down the account by prepaying burial/funeral arrangements but did not notify her that the account was over $2,000.
Failure to Follow Care Plan for Nail Care and Oxygen Therapy
Penalty
Summary
The facility failed to follow the comprehensive care plan for a resident with diagnoses including type 1 diabetes mellitus with hyperglycemia, reduced mobility, and need for assistance with personal care. The care plan, initiated 12/25/2025, directed staff to assist with bathing as needed per the resident schedule, monitor skin during bathing, and have the nurse assist with nail care on scheduled bath days and as needed. The resident was scheduled for baths on Monday, Wednesday, and Friday on night shift, but observations on 03/27/2026 and 03/28/2026 showed long, untrimmed fingernails with visible debris and a brown substance under the nail beds. During observations and interviews, a CNA, an LPN, and another CNA confirmed the condition of the resident’s fingernails, and the LPN stated that nurses and CNAs were responsible for nail care. The facility also failed to follow the care plan for a resident with acute chronic respiratory failure with hypoxia. Physician orders dated 02/14/2026 directed oxygen at 2 liters per minute via nasal cannula, but the care plan listed the diagnosis and included interventions that did not reflect the ordered oxygen setting. During interview, the MDS Coordinator stated that the physician order was for oxygen to be set at 2 liters per minute and confirmed that 1.5 liters per minute was the wrong setting. The MDS Coordinator also stated that staff were expected to follow the care plan.
Failure to Provide Nail Care for a Resident Needing ADL Assistance
Penalty
Summary
The facility failed to ensure nail care was provided for one resident who was unable to perform activities of daily living independently. R28 had diagnoses including type 1 diabetes mellitus with hyperglycemia, other reduced mobility, and need for assistance with personal care. The resident’s MDS showed a BIMS score of 7, no rejection of care, and dependence on staff for ADL care. The facility’s policy stated that nail care includes daily cleaning and regular trimming, with diabetic residents’ nail trimming done per MD order, and podiatry care scheduled as needed for residents with identified podiatry needs. R28 was scheduled for bathing on Monday, Wednesday, and Friday nights, and the facility’s documentation survey report from January 2026 through March 2026 showed no refusal of ADL bathing or personal hygiene related to nail care. However, during multiple observations, R28 was seen with long, untrimmed fingernails and visible debris containing a brown substance underneath the nail beds. A CNA, an LPN, the DON, and the RN Unit Manager all confirmed the condition of the resident’s fingernails. The LPN stated that nurses and CNAs were responsible for nail care, the DON stated staff were expected to provide nail care on bath days as scheduled, and the RN Unit Manager stated CNAs were responsible for nail care and nurses were responsible for trimming the nails of residents with diabetes.
Oxygen Flow Rate Not Set as Ordered
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not maintained for R31, who had diagnoses including acute chronic respiratory failure with hypoxia. The resident’s MDS indicated a BIMS of 7, shortness of breath, and receipt of oxygen therapy. Physician orders dated 02/14/2026 directed oxygen at 2 liters per minute via nasal cannula, and the facility policy for Respiratory System Management directed staff to check the physician’s orders and turn the flow meter to the ordered flow rate. Observations on 03/27/2026 and 03/28/2026 showed R31 lying in bed receiving oxygen via nasal cannula at 1.5 liters per minute instead of the ordered 2 liters per minute. During rounding with the DON, the DON confirmed nurses were responsible for ensuring the oxygen setting matched the prescribed rate during medication pass and rounding and verified the rate should have been 2 liters per minute. An LPN confirmed the order was for 2 LPM and stated she had not checked R31’s oxygen as of the time of interview. The DON later stated she found the oxygen rate off by a half liter because the concentrator was faulty and was unsure how long it had been broken.
Failure to Implement Advanced Directive Care Plan for Full Code Resident
Penalty
Summary
The facility failed to implement the Advanced Directive care plan for a resident who was designated as Full Code, resulting in CPR not being performed when the resident was found without a pulse or respirations. The resident had a documented history of cerebral atherosclerosis, dysphagia, gastro-esophageal reflux disease, anemia, constipation, hypertension, and hyperlipidemia. The clinical record, physician's orders, and care plan all specified that the resident was to be a Full Code and that resuscitation (CPR) should be attempted. The resident was also admitted to hospice services, but the POLST form and care plan continued to specify Full Code status. On the day of the incident, staff discovered the resident deceased and documented the absence of pulse and respirations, but there was no evidence that CPR was attempted as required by the care plan and physician's orders. Interviews with staff, including the DON, revealed a misunderstanding among nursing staff, who believed that hospice admission automatically changed the resident's code status to DNR, despite clear documentation to the contrary. The deficiency occurred during a shift change, and the DON confirmed that no resuscitation efforts were made.
Failure to Initiate CPR for Full Code Resident Due to Staff Misunderstanding
Penalty
Summary
Facility staff failed to assess and implement life-sustaining measures for a resident who was found unresponsive, despite the resident's advanced directives and physician orders specifying full code status and to attempt CPR. The facility's Emergency Response Management and Cardiopulmonary Resuscitation (CPR) policies required staff to initiate CPR in the event of cardiac or respiratory arrest for residents with full code status. The resident, who had diagnoses including cerebral atherosclerosis and was receiving hospice services, had a current POLST form and physician's order indicating that CPR should be attempted. On the day of the incident, the resident was noted by a CNA to be cold and not feeling well, and this was reported to the assigned LPN. Later, when the CNA returned to check on the resident, she found the resident cold and called for help. Multiple staff, including CNAs and LPNs, became aware that the resident was unresponsive and had no pulse or respirations. However, none of the nurses present checked the resident's code status or initiated CPR, as required by the resident's directives and facility policy. The DON later confirmed that staff mistakenly believed that hospice status implied a Do Not Resuscitate (DNR) order, despite documentation to the contrary. Interviews with staff revealed confusion during the shift change, with day and night shift nurses deferring responsibility to each other and not responding to the resident's room when alerted. The night shift LPN, upon being notified by a CNA, assessed the resident and confirmed the absence of vital signs but did not attempt CPR or verify code status. The failure to initiate CPR was not due to lack of policy or documentation, but rather staff assumptions and lack of verification regarding the resident's code status.
Failure to Honor Advance Directive for Full Code Resident
Penalty
Summary
Facility nursing administration failed to provide effective oversight to ensure that nursing staff assessed and implemented the correct Advance Directive for one of eleven sampled residents reviewed for Advance Directives. The resident, who had diagnoses including cerebral atherosclerosis, dysphagia, gastro-esophageal reflux disease, anemia, constipation, hypertension, and hyperlipidemia, was admitted to hospice services but maintained a Full Code status as specified in both the physician's order and the updated POLST form. The resident's responsible party also confirmed the desire for Full Code status. Despite these clear directives, when the resident was found without a pulse or respirations, there was no evidence that CPR was attempted by facility staff. Interviews with the DON revealed that nursing staff mistakenly believed that hospice admission automatically meant Do Not Resuscitate (DNR) status, leading to the failure to initiate CPR. The incident occurred during a shift change, with both day and night shift nurses present in the facility. The DON confirmed that the staff were already notifying hospice when she arrived at the resident's room and that she was later informed by staff that the resident was a Full Code. Documentation and staff interviews confirmed that the resident's wishes for resuscitation were not honored at the time of death.
Lack of Alternate Meal Options for Residents
Penalty
Summary
The facility failed to provide residents with appealing meal options that accommodate their preferences, as required by their policy. During a Resident Council meeting, residents expressed dissatisfaction with the lack of alternate meal choices, stating that if they did not like the meal served, their only options were a sandwich or soup. The facility's fall/winter menu did not include alternate meal choices for lunch or dinner, and interviews with dietary staff confirmed that no alternate hot entrees were available. The Registered Dietician acknowledged the absence of alternate meal options and attributed it to budget constraints, noting that no alternate menus had been requested from the vendor. One resident, who had been at the facility for a year, reported never having a choice of meals and not being offered an alternate meal if she disliked the one served. Observations during the survey confirmed the absence of alternate meals on the menu and the hot steam tray unit during meal service. Interviews with the Dietary Manager, Dietary Aids, and the Administrator revealed a consistent practice of offering only sandwiches or soup as alternatives, with no hot meal options available. The Administrator was aware of the issue but stated that residents could receive a grilled cheese sandwich if requested.
Expired Food Items Found in Facility's Stand-Up Cooler
Penalty
Summary
The facility failed to adhere to its food storage policy, which mandates that leftover food be stored in covered containers, clearly labeled, dated, and used within 48 hours or discarded. During a kitchen tour, surveyors observed expired food items in the stand-up cooler, including a resealable plastic bag of sliced ham and a plastic container of chicken and noodles, both past their expiration dates. The Dietary Manager confirmed the presence of these expired items and discarded them, acknowledging that the expectation was for staff to dispose of items before they expire. This oversight had the potential to affect 50 of the 53 residents receiving an oral diet, posing a risk of illness to the residents.
Infection Control Deficiency in Tracheostomy Care
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols during tracheostomy care for a resident with multiple diagnoses, including tracheostomy status and acute respiratory failure. During an observation, it was noted that RN AA did not perform hand hygiene after donning and doffing gloves throughout the tracheostomy care procedure, which is a deviation from the facility's policy. Additionally, RN AA placed soiled towels in a yellow plastic trash bag and left it on the floor for two hours, which is not in line with proper disposal practices. The resident involved was non-verbal and had a tracheostomy in place, secured with ties, and was receiving oxygen via a trach collar. Interviews with the staff revealed that LPN CC, who assisted with the procedure, had not received in-service training on tracheostomy care, and RN AA acknowledged the failure to wash hands as required. The Director of Nursing confirmed the expectation for hand hygiene and glove changes during the procedure, and LPN BB later removed the improperly placed trash bag from the floor.
Failure to Maintain Clean Environment in Resident Room
Penalty
Summary
The facility failed to maintain a clean and homelike environment in Room 33, as evidenced by the presence of a brown stain and a white chalky substance on the privacy curtain. Observations were made on three separate occasions, confirming the deficiency. The facility's cleaning schedule indicated that Room 33 was not deep cleaned in January or February 2025, despite the facility's policy requiring monthly deep cleaning of each resident's room, including checking and replacing soiled privacy curtains. Interviews with the housekeeping staff and the Account Manager revealed that the facility has a five-step daily cleaning process and a seven-step deep cleaning process, both of which include checking the curtains for stains. However, the housekeeper responsible for cleaning Room 33 admitted to not noticing the soiled curtains during her cleaning routine. The Administrator confirmed that the housekeeping staff is expected to follow these cleaning steps to ensure a clean environment for residents.
Failure to Provide Written Transfer Notification
Penalty
Summary
The facility failed to provide a written reason for transfer to a resident or their representative, as required by their policy. The policy, dated February 2015, mandates that the resident or their family/responsible party be notified in writing of a transfer, except in cases of unplanned, acute clinical needs where verbal communication is followed by written documentation in the medical record. However, for a resident with unspecified dementia and type 2 diabetes mellitus with hyperglycemia, there was no evidence of a written reason for transfer provided to the resident's representative during two hospitalizations. Interviews with facility staff, including LPNs and the Business Officer Manager, revealed that the facility's practice was to verbally notify the family or representative of the reason for transfer but not to provide written documentation. The Director of Nursing confirmed that no written notification was given because the facility expected the resident to return. This practice was inconsistent with the facility's policy and resulted in a deficiency being identified during the survey.
Failure to Provide Written Bed Hold Notice
Penalty
Summary
The facility failed to provide a written notice of bed hold to a resident's representative during two separate hospital transfers. The facility's policy, revised on 3/3/2020, mandates that a copy of the bed hold agreement be provided to the resident or responsible party prior to a transfer or within 24 hours in case of an emergency transfer. However, for a resident with diagnoses including unspecified dementia and type 2 diabetes mellitus, there was no evidence of a bed hold notice being provided during hospital transfers on 5/13/2024 and 12/18/2024. An unsigned bed hold agreement was found in the resident's record for the latter date. Interviews with facility staff revealed a lack of adherence to the policy. An LPN stated that while a document including a bed hold agreement is completed and given to emergency medical services, it is not provided to the resident or their representative. The Business Officer Manager confirmed that the facility only calls the family representative to notify them of the bed hold agreement, without providing written documentation. The Director of Nursing also verified that no written notice is given to the representative, as the facility assumes the resident will return.
Failure to Follow Oxygen Administration Care Plans
Penalty
Summary
The facility failed to adhere to the care plans for three residents regarding oxygen administration, as observed and confirmed through record reviews and staff interviews. Resident 12, diagnosed with COPD and hypoxemia, was observed receiving oxygen therapy at 7 liters per minute, contrary to the physician's order of 3 liters per minute. This discrepancy was confirmed by both the LPN and the Director of Nursing, who acknowledged the failure to follow the care plan. Similarly, Resident 7, with a diagnosis of COPD, had a physician's order for oxygen at 2 liters per minute as needed, but the care plan was not followed as verified by the MDS Coordinator. Resident 14, diagnosed with acute respiratory failure, was supposed to receive oxygen at 4 liters per minute via trach collar according to the physician's order. However, the care plan was not adhered to, as confirmed by the MDS Coordinator and the DON. The facility's policy on care planning management was not effectively implemented, leading to these deficiencies in care. The MDS Coordinator and the DON both expressed expectations that staff should follow the care plans, which clearly outlined the required oxygen administration for each resident.
Failure to Follow Physician Orders for Oxygen Administration
Penalty
Summary
The facility failed to adhere to physician orders for oxygen administration for three residents, leading to a deficiency in respiratory care. Resident 12, diagnosed with COPD and hypoxemia, was observed receiving oxygen therapy at 7 liters per minute, contrary to the physician's order of 3 liters per minute. Licensed Practical Nurse EE admitted to not checking the oxygen settings during medication pass, which is when the settings should have been verified. The Director of Nursing (DON) confirmed that staff are expected to ensure oxygen is administered as ordered. Similarly, Resident 7, with a diagnosis of COPD, was receiving oxygen at 3 liters per minute instead of the prescribed 2 liters per minute. LPN BB acknowledged the oversight in checking the oxygen rate during the morning medication pass. Resident 14, diagnosed with acute respiratory failure, was receiving oxygen at 5 liters per minute via trach collar, instead of the ordered 4 liters per minute. LPN BB again admitted to not verifying the oxygen rate as per the physician's order. The DON reiterated the expectation that oxygen settings should be checked during medication pass, as oxygen is considered a medication.
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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