Murray Woods Of Journey Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Chatsworth, Georgia.
- Location
- 102 Hospital Drive, Chatsworth, Georgia 30705
- CMS Provider Number
- 115280
- Inspections on file
- 19
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Murray Woods Of Journey Llc during CMS and state inspections, most recent first.
The facility failed to prevent sexual abuse when a cognitively impaired resident with dementia and behavioral disturbances repeatedly wandered into other residents’ rooms and got into their beds, often lying on top of them, despite ongoing documentation and staff awareness of these behaviors. Nursing notes and staff interviews described this pattern as common, with redirection attempts by CNAs and LPNs noted as unsuccessful. Another cognitively impaired resident was later found in bed with this resident on top of her, his pants down and attempting to kiss her while she screamed, and prior concerns had been raised by her family about unexplained blood on her lip and changes in her condition. These events occurred even after environmental changes to a previously locked dementia unit, while staff continued to regard the behavior as typical for the resident.
The facility failed to ensure adequate nursing staff to meet the needs of its 116 residents, resulting in excessively low weekend staffing and a one-star staffing rating for Quarter 1 of 2024. Despite efforts to use agency staff, the facility's staffing levels were insufficient.
The facility failed to serve the meal listed on the cycled menu, affecting 115 residents. Instead of the listed ham and California vegetable blend, residents received a sloppy joe. Interviews and a photo confirmed the deviation, and the Administrator acknowledged the issue, noting sufficient ingredients were available.
The facility failed to provide a safe, clean, and homelike environment in nine resident rooms and the lobby media common area. Observations revealed pests, damaged fixtures, dirty walls, and crowded furniture. Interviews confirmed these issues, and the Administrator acknowledged the unacceptable conditions, requesting immediate action.
The facility failed to enforce its smoking policy, allowing a resident with serious health conditions to vape unsupervised in his room. Despite the policy requiring supervision and designated smoking areas, the resident was observed vaping multiple times without staff intervention.
The facility failed to ensure residents were free of medication administration errors exceeding 5 percent. One nurse did not have a resident rinse their mouth after using an inhaler, and another nurse did not properly disinfect a PICC line lumen, both actions contrary to facility policies.
A facility failed to follow proper infection control practices when flushing a PICC line for a resident. An LPN was observed wiping the needleless connector only once instead of the required five seconds. The resident had multiple diagnoses, including osteomyelitis and cellulitis, and there was no physician's order for the PICC line flushes. The DON confirmed the expectation to disinfect the connector for at least five seconds.
Failure to Prevent Ongoing Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to prevent sexual abuse between residents and to protect residents from non-consensual sexual contact as required by its Abuse, Neglect, and Exploitation policy. The policy states the facility will prohibit and prevent abuse, neglect, and exploitation, including non-consensual sexual contact of any type with a resident. Despite this, one resident (R1), who had significant cognitive impairment with a BIMS score of 08 and diagnoses including vascular dementia, bipolar disorder, anxiety disorder, and dementia with behavioral disturbances, repeatedly entered other residents’ rooms and beds. Nursing notes over several months documented R1 attempting to go into other residents’ rooms, climbing into their beds, wandering hallways, and being found lying on top of other residents, both male and female, with staff redirection attempts noted as unsuccessful. Multiple nursing notes described specific incidents where R1 was found in bed with other residents. On one occasion, a nurse documented that R1 was found in another patient’s room lying asleep on top of another patient and was assisted off. Another note the same date documented that another patient was in R2’s room and laid down on top of her and went to sleep, and that the other patient was removed and returned to their room. Subsequent notes indicated that R1 continued to try to get into bed with residents and that he was wandering up and down hallways and going in and out of other residents’ rooms, with continued attempts to enter a specific female resident’s room despite redirection. Staff interviews confirmed that it was common and “normal” for R1 to get in and out of bed with other residents and to lie on top of them, and that CNAs routinely reported these behaviors to nursing staff. R2 was a resident who could not complete the BIMS, indicating significant cognitive impairment. A nurse note documented that R2’s daughter was concerned after finding blood on R2’s bottom lip and that R2 was not herself. Later, a nurse note recorded that R2’s responsible party was notified that another resident had been found in bed with R2, with his pants down and his lips on hers. The facility’s investigation included a CNA’s written statement that R1 was found in R2’s bed with his pants and underwear off, on top of R2, holding her by both arms and attempting to kiss her while R2 screamed. Another CNA interview described finding R1 on top of R2 with her arms pinned down, his face very close to hers, and his pants pulled down. Staff, including the Social Services Assistant and LPNs, acknowledged that R1’s behaviors of getting into bed with other residents were ongoing, that redirection was ineffective, and that these behaviors occurred both when R1 was on a locked dementia unit and after the unit doors were removed, yet R1 continued to have access to other residents and their rooms.
Inadequate Nursing Staff
Penalty
Summary
The facility failed to ensure adequate nursing staff to meet the needs of its 116 residents. The Facility Assessment Tool (FAT) for 2024 indicated that the average daily census was 112 residents, requiring 84 hours of licensed nurses and 233 hours for nurses' aides per day. However, the Payroll-Based Journal (PBJ) Staffing Data Report for Quarter 1 of 2024 revealed that the facility had excessively low weekend staffing and received a one-star staffing rating. This rating was due to several factors, including failure to submit PBJ data by the deadline, more than four days in the quarter without RN staffing hours, and failure to respond to or pass a CMS audit for PBJ data discrepancies. Interviews with the Director of Nursing (DON) and the Human Resources Director/Nursing Scheduler (NS) revealed that they were unaware of the one-star staffing rating and excessively low weekend staffing. The DON mentioned that extra staff were scheduled for weekends to cover call-offs, and the NS stated that agency staff were used to meet staffing numbers. However, the Administrator acknowledged awareness of the staffing issues and mentioned efforts to subsidize with agency staff. Despite these efforts, the facility's staffing levels were insufficient to meet the residents' needs, leading to the identified deficiency.
Failure to Serve Menu-Listed Meal
Penalty
Summary
The facility failed to serve the meal listed on the cycled menu for residents who received an oral diet from the kitchen. Specifically, the cycled menu stated ham and California vegetable blend was to be served for dinner, but instead, a sloppy joe was served. This deficiency affected 115 of 116 residents who received an oral diet from the kitchen. The facility policy titled 'Menus' updated in February 2017, mandates that all residents receive the meal stated on the weekly menu, which was not followed in this instance. The weekly menu cycle for the week of Sunday, 5/26/2024, indicated that residents were to receive glazed baked ham, pinto beans, broccoli, and cornbread, but this was not adhered to. Interviews with residents and staff revealed dissatisfaction with the meal served. Residents reported receiving a bag of potato chips and a spoon of watered-down sloppy joe chili on a slice of white bread instead of the listed menu items. A photo taken by a resident confirmed this. During a Resident Council meeting, several alert and oriented residents confirmed they received sloppy joe on a slice of bread instead of glazed ham. The Corporate Registered Nutritionist and the Administrator acknowledged receiving complaints and confirmed that there was sufficient ham and hamburger buns available in the kitchen. The Cook responsible for serving the meal did not provide an explanation for the deviation from the menu. The Administrator expressed shock and disappointment in the Cook's behavior, noting that she is a seasoned kitchen cook.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment in nine of 53 resident rooms on two of four halls, and in the lobby media common area. Observations revealed multiple deficiencies including the presence of pests (flies), damaged floor fall strips, dirty wall sheetrock, dirty privacy curtains with missing hanging hooks, stained and damaged floor tiles, damaged bathroom toilet commodes, damaged baseboards, dirty and broken PTAC unit vent covers, damaged soap dispensers, and crowded furniture in the lobby media common area. Specific rooms were noted to have flies on residents' pillows and floors, dirty walls, damaged floor fall strips, unattached soap dispensers, dirty PTAC units, missing paint on bedroom sinks, big holes in walls, and damaged bathroom fixtures. Additionally, the lobby media common area was observed to have crank beds pushed against the wall, creating a crowded environment for residents watching television. Interviews with the Administrator, Assistant Maintenance Director (AMD), and Housekeeping/Laundry Director (HLD) confirmed the presence of pests, damaged and dirty fixtures, and crowded furniture. The HLD mentioned that a cleaning audit of privacy curtains was in progress, and the AMD stated that pest control services had been conducted but was unsure of the specific measures taken for flies. The Administrator acknowledged the unacceptable conditions and requested immediate action to address the issues. The AMD also confirmed and fixed the missing back of the commode top in one of the rooms during the walk-through.
Failure to Enforce Smoking Policy
Penalty
Summary
The facility failed to enforce its smoking policy adequately for one resident, allowing him to vape unsupervised in his room. The facility's policy required that electronic cigarettes be used only in designated smoking areas under supervision. Despite this, the resident was observed multiple times vaping in his room without supervision. The resident's medical record indicated several serious health conditions, including cerebral infarction and psychotic disorder, and his care plan included specific interventions to ensure safety during smoking times. However, these interventions were not followed, as evidenced by the repeated observations of the resident vaping in his room. During the survey, the resident was seen vaping in his room on several occasions, and staff members did not notice or address the vaping device on the bedside table. The Director of Nursing and the Administrator confirmed that vaping in rooms was against the facility's policy and that staff were required to confiscate vaping devices and ensure residents only vaped under supervision. Despite this, the resident continued to vape unsupervised, indicating a failure in policy enforcement and staff supervision.
Medication Administration Errors Exceeding 5 Percent
Penalty
Summary
The facility failed to ensure that residents were free of medication administration errors of more than 5 percent. Specifically, one nurse did not have a resident rinse their mouth after administering a Breo inhaler, which is required per manufacturer recommendations. The resident, who had moderate cognitive impairment and was diagnosed with Parkinson's disease and chronic obstructive pulmonary disease (COPD), did not rinse their mouth after the inhaler was administered. The nurse acknowledged forgetting this step when questioned immediately after the administration. Another nurse failed to properly disinfect the lumen of a peripherally inserted central catheter (PICC) line for a resident with osteomyelitis of the vertebra, obstructive and reflux uropathy, and cellulitis of both lower legs. The nurse only wiped the needleless connector once with an alcohol wipe instead of performing a vigorous mechanical scrub for five seconds as required by the facility's policy. When asked about the proper procedure, the nurse admitted to not knowing the correct duration for disinfecting the PICC line port.
Improper Infection Control Practices for PICC Line Flushing
Penalty
Summary
The facility failed to use proper infection control practices when flushing a needleless connector of a peripherally inserted central catheter (PICC) for a resident (R111). The facility's policy required disinfecting the needleless connector with an antiseptic solution using a vigorous mechanical scrub for five seconds and allowing it to dry completely. However, during an observation of medication administration, an LPN was seen wiping the alcohol wipe across the needleless connector just once before flushing the catheter and again wiping it once before applying the cap. This practice did not comply with the facility's policy and had the potential to cause infection for the resident. The resident, R111, was admitted with diagnoses including osteomyelitis of the vertebra, obstructive and reflux uropathy, and cellulitis of the right and left lower legs. The resident's care plan included administering IV antibiotic medications as per the medical doctor's order. However, there was no physician's order for the PICC line flushes in the electronic medical record. When interviewed, the LPN could not specify the required time for disinfecting the PICC line port, and the Director of Nursing confirmed that nurses should disinfect the needleless connector for at least five seconds, as per the facility's policy.
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Surveyors found that clean linens and personal clothing were stored and staged in close proximity to the dirty laundry area, with an open door between the clean and soiled sides and all washer and dryer doors open. Clean resident clothes, unlabeled garments, and bagged items were placed next to dryers and directly in front of the dirty linen room, and dirty barrels had to be pushed past racks of clean clothing to reach the washers, contrary to facility policies requiring separation of clean and soiled linens. Environmental staff believed keeping doors open and covering dirty barrels reduced infection spread, while the Environmental Services Director, IP nurse, and Administrator acknowledged that the dirty room door should be closed, linens should not be on dirty barrels, and clean resident clothing should not be stored in that location.
A resident with a suprapubic catheter, colostomy, sacral wound, and dependence on staff for bathing and hygiene was care planned for Enhanced Barrier Precautions (EBP), including use of PPE during high-contact care. During observed catheter care and a bed bath, a CNA wore only gloves and did not don a gown, despite EBP signage and a star posted on the door and PPE supplies available outside the room. In interviews, the CNA admitted forgetting to wear a gown and not recognizing additional required actions, while the IP nurse and DON confirmed that staff had been educated that gowns and gloves are required for high-contact care involving indwelling devices and wounds under the facility’s EBP policy.
A resident with multiple neurologic and psychiatric diagnoses, intact cognition, and unilateral functional limitations was found with an open box of lubricant eye drops stored at the bedside without any documented assessment for self-administration or prescriber’s order for self-administration or bedside storage, contrary to facility policy. Observations on multiple days confirmed the eye drops remained at the bedside, while staff interviews showed that CNAs and the IP recognized that residents were generally not to self-administer medications and that bedside medications required assessment and orders. The Administrator confirmed that the resident should not have had eye drops in the room and that residents with bedside medications are typically assessed for self-administration, and staff acknowledged that unsecured eye drops at the bedside could be accessed or ingested by other residents and cause harm.
The facility failed to maintain a safe, clean environment when multiple ceiling tiles throughout the building, including above a resident’s bed, near the nurses’ station, in a glass day room above a resident’s chair, and in a main hall, were observed with brown circular stains, bulging, and a white moldy substance. The Maintenance Director confirmed the stained and bulging tiles, acknowledged the risk that tiles above a resident’s bed could fall, and attributed the condition to rain-related roof leaks. The Administrator also confirmed that roof leaks and recent rainfall caused the brownish stains despite her reported daily rounds.
A resident with severe cognitive impairment, on hospice and fully dependent for ADLs, was sexually abused when another cognitively impaired male resident with a long-standing history of sexually inappropriate behavior toward female residents entered her room and placed his hand inside her pants. The abusing resident had multiple dementia and psychiatric diagnoses, was care planned for sexually inappropriate behaviors with prior documented incidents, and was on psychotropic medication for OCD-related sexual obsession. Despite these known risks and existing care plan interventions, he was able to access the female resident’s room and make inappropriate physical contact, and the facility’s investigation substantiated the abuse.
Surveyors found that the facility failed to develop and implement complete, person-centered care plans for two residents. One resident was receiving an antipsychotic (Haloperidol) for schizophrenia with associated behavior and side-effect monitoring orders, but there was no corresponding care plan addressing antipsychotic use or its indication. Another resident had an indwelling Foley catheter for neurogenic bladder related to prostate cancer, with goals to prevent catheter-related trauma; however, the care plan omitted key interventions such as balloon volume parameters and use of a leg strap or securement device, despite physician orders requiring a leg strap and observations showing the catheter positioned under the leg without securement. An MDS coordinator and the administrator acknowledged that required interventions and standard catheter care components were missing from the care plans.
A resident with a history of resistiveness to care and noncompliance with the non‑smoking policy had a comprehensive care plan that was not updated to reflect multiple interventions implemented in response to repeated smoking and vaping violations. Although the care plan noted the need for supervision while smoking and review of the smoking policy, it did not include measures such as daily room searches for smoking materials, added smoke detection in the room, relocation closer to the nurses’ station, q2h visual rounds for smoke, post‑outing nursing checks, initiation of a PAR process for vaping, or issuance of a discharge notice. Facility forms showed inconsistent documentation of daily room searches and incomplete IDT documentation on the PAR tracking, despite multiple documented episodes of policy violations and removal of vaping devices.
A cognitively intact but physically impaired resident with a history of noncompliance with the facility’s non‑smoking policy repeatedly smoked and vaped in his room while keeping multiple vape devices and other items at bedside. The facility’s Smoking Policy required that non‑compliant smokers have daily documented searches and be prohibited from keeping smoking materials in their rooms, yet monitoring forms showed many days without documented searches, Patient at Risk tracking was incomplete, and staff acknowledged that daily room checks and frequent rounds were not consistently performed. Multiple staff, including a CNA, social worker, Infection Preventionist, MDS coordinator, Activities Director, and the Administrator, reported ongoing violations and repeated discovery of vape devices in the resident’s room, including during surveyor observations, demonstrating that the environment was not maintained free from accident hazards and that required supervision and monitoring were not reliably implemented.
Surveyors found that a treatment cart containing topical medications was left unlocked and unattended in a hall across from a resident’s room after wound care was completed by an LPN. The facility’s policy requires that medication carts and supplies be locked or attended and accessible only to licensed or otherwise authorized staff. During interviews, the LPN confirmed the cart had been left unlocked and unattended, the IP LPN confirmed the LPN’s report that the cart was left unlocked, and the Administrator stated that all medications, including topical medications, were expected to be locked when not in sight of authorized staff.
The facility failed to implement its infection prevention and control program by not operationalizing a documented Legionella water management plan despite having a written policy, and by not fully implementing Enhanced Barrier Precautions (EBP) for residents with indwelling devices and other risks. A resident with an indwelling urinary catheter had no EBP care plan or orders, no EBP signage, and staff providing catheter care wore only gloves without gowns, while multiple staff members reported not knowing what EBP was or misidentified who should be on EBP. Another resident receiving tube feeding had care initiated by an LPN who wore gloves but no gown and repeatedly touched her hair with the same gloved hands before handling the feeding tube and equipment, later acknowledging she should have changed gloves and was unaware of EBP requirements, even though other clinical staff stated gowns and gloves should be used for feeding tube care. A resident on isolation for C. diff had a door sign indicating isolation but no instructions for visitors on required PPE or to seek staff guidance, and the IP confirmed there was no system to direct visitors about precautions, contributing to the overall infection control deficiency.
Failure to Maintain Separation of Clean and Soiled Laundry
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to separation of clean and soiled linens. Facility policies titled “Infection Prevention and Control Program” and “Handling Soiled Linens” required that clean linen always be separated from soiled linen. During an observation of the laundry area, all washer and dryer doors were open in the clean linen area. Clean linens, including sheets, towels, blankets, and washcloths, were folded on a table to the left of the washer and dryer room. On the right side of the room, next to the dryers and directly in front of the open door to the dirty laundry room, there were residents’ clean clothes on a rack, piles of folded clean clothes to be hung, a rack of unlabeled clothes, and a bag of unlabeled clothes. Dirty laundry barrels had to be pushed past the clean clothing on the racks to reach the washers, placing soiled items in close proximity to clean items despite policy requirements for separation. Environmental staff working in the laundry stated they believed they were reducing the spread of infection by keeping all doors open, covering dirty barrels, and circulating air, and they explained that the uncovered rack and bagged clothes near the dirty area were no-name clothes sometimes distributed to residents in need. They also stated that the rack of clean personal resident clothing parked in front of the open dirty linen room door was awaiting distribution by a staff member who worked only at night. The Environmental Services Director reported that the door to the dirty side of the laundry should always be closed and that no linen should be on top of dirty barrels. The Infection Preventionist nurse, when shown pictures and concerns about cross-contamination, confirmed there was a problem in the laundry but stated she had not been aware of it previously. The Administrator stated that residents’ clothes should not be stored where they were observed and should be handed out immediately once clean, and that she expected the laundry to be organized to prevent cross-contamination between dirty and clean clothes.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff followed its Enhanced Barrier Precautions (EBP) policy for the use of personal protective equipment (PPE) during high-contact care. The facility’s EBP policy, updated February 2025, requires gowns and gloves for residents with wounds and/or indwelling medical devices, including urinary catheters and ostomies, when staff perform high-contact activities such as bathing, dressing, toileting, hygiene, and catheter care. The policy also directs that gowns and gloves be made available near or outside the resident’s room and that EBP be implemented for residents with indwelling devices or wounds, even if they are not known to be infected or colonized with a multidrug-resistant organism. The resident involved had a suprapubic catheter, colostomy, sacral wound, and neurogenic bladder and bowel, and was care planned for EBP implementation during catheter and skin care. The resident was cognitively intact but dependent on staff for bathing, dressing, toileting, hygiene, bed mobility, and transfers, and used an indwelling catheter and ostomy. During an observation, a CNA provided suprapubic catheter care and a bed bath to this resident while only wearing gloves, despite EBP signage and a star posted on the door and PPE supplies available outside the room. The CNA did not don a gown and was unable to identify any additional actions needed before care until prompted about the EBP signage, at which point he acknowledged he should have worn a gown but forgot. In a subsequent interview, the IP nurse and DON confirmed that staff had been educated that gowns are required during high-contact care for residents with catheters, colostomies, and other devices, and that the posted signage and star were intended to alert staff to the need for enhanced PPE use.
Failure to Assess and Obtain Orders for Self-Administration and Bedside Medication Storage
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policies for self-administration of medications and bedside medication storage for one resident. The facility’s policies require that residents who wish to self-administer medications must be assessed by the interdisciplinary team for cognitive, physical, and visual ability, and that a prescriber’s order for self-administration and bedside storage must be present in the medical record and reflected on the MAR and medication label. For the resident in question, who had diagnoses including cerebral infarction, major depressive disorder with psychotic symptoms, PTSD, hemiplegia and hemiparesis, speech and language deficits, and cerebral atherosclerosis, the EHR showed no assessment for self-administration and no physician order for self-administration or bedside storage, despite active ophthalmic medication orders. The resident’s MDS documented intact cognition with a BIMS score of 15, use of corrective lenses, and functional limitations in range of motion on one side of both upper and lower extremities. Surveyor observations on two consecutive days found an open box of lubricant eye drops on the resident’s bedside table. Staff interviews revealed inconsistent understanding and enforcement of the facility’s policies. A CNA stated that residents did not self-administer medications and that only nurses administered them, but also reported that when she previously reported the eye drops, she was told the resident could have them because he was independent. The Infection Preventionist acknowledged the resident had an order for eye drops and believed he obtained them from the VA, and stated he should not have the lubricant eye drops because they were a hazard for other people. The Administrator confirmed that typically a resident with medications at the bedside should be assessed for self-administration and stated the resident should not have eye drops in his room. The report notes that unsecured medications at the bedside had the potential to cause adverse reactions if accessed or ingested by other residents.
Failure to Maintain Safe and Clean Ceiling Surfaces Throughout Facility
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable homelike environment as required by its Maintenance Service policy, which assigns the Maintenance Department responsibility for keeping the building in good repair and free from hazards. Surveyors observed multiple stained and damaged ceiling tiles in several areas of the facility, including near the nurses' station, in a resident bedroom (room [ROOM NUMBER]A), in the glass day room, and in the middle of the east hall. On several occasions, ceiling tiles near the nurses' station were noted to have tannish-brown circular stains of varying sizes, and at one point a white, moldy substance was observed on a ceiling tile in that same area. In room [ROOM NUMBER]A, surveyors observed brown rings roughly 16 inches in diameter on ceiling tiles located directly above a resident’s bed, with the Maintenance Director later confirming that these tiles were stained, bulging, and at risk of falling on the resident. Additional observations in the glass day room identified two stained ceiling tiles above a resident’s chair, each with brown circular stains approximately three inches in diameter. In the east hall, a ceiling tile with a brown circular stain approximately 10 inches in diameter was also documented. The Maintenance Director and the Administrator both acknowledged that the stains and damage were related to roof leaks associated with recent rainfall, and the Administrator confirmed awareness of roof leaks that had previously been repaired and that the brownish stains were due to recent rain.
Failure to Prevent Sexual Abuse of a Cognitively Impaired Resident by Another Resident
Penalty
Summary
The facility failed to protect a dependent, cognitively impaired resident (R113) from sexual abuse by another resident (R12). R113 had severe cognitive impairment with a BIMS score of 5, was on hospice care, and was fully dependent for toileting, bathing, dressing, footwear, and personal hygiene. On the day of the incident, a CNA observed R12 in R113’s room with his right hand inside R113’s pants while she was seated in a geriatric chair. Staff witness statements and nursing progress notes documented that R12 was found in R113’s room with his hand in her pants, and the facility’s investigation substantiated that R12 touched R113 inappropriately. R12 also had severe cognitive impairment with a BIMS score of 4 and multiple psychiatric and dementia-related diagnoses, including vascular dementia with mood disturbance, Alzheimer’s disease, major depressive disorder, obsessive-compulsive personality disorder, unspecified psychosis, and unspecified mood affective disorder. He required extensive physical assistance, used a manual wheelchair, and was fully dependent for toileting, bathing, lower body dressing, and footwear. R12’s care plan, in place since 2017, identified him as having sexually verbally and physically inappropriate behavior, including documented prior incidents in which he inappropriately touched or attempted to touch female residents. His care plan included interventions such as discussing his behavior when reasonable, explaining that it was inappropriate, intervening to protect others, diverting his attention, and removing him from situations as needed, as well as monitoring and recording occurrences of target behaviors such as sexual aggression toward others. Despite this known history of sexually inappropriate behavior toward female residents and the presence of care plan interventions, R12 was able to enter R113’s room and place his hand inside her pants. The Administrator confirmed that the CNA reported finding R12 in R113’s room with his hand in her pants while R113 was in her wheelchair, and that the facility’s investigation substantiated the abuse allegation. The facility’s abuse policy stated that it would not condone resident abuse by anyone, including other residents, and defined sexual abuse to include sexual harassment, sexual coercion, or sexual assault. The occurrence of this incident demonstrated that the facility did not effectively prevent sexual abuse of R113 by another resident, despite R12’s documented behavioral history and existing care plan.
Failure to Develop and Implement Complete Care Plans for Antipsychotic Use and Foley Catheter Management
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for identified resident needs, as required by its Comprehensive Care Plan policy. The policy states that care plans must address all needs identified in the comprehensive assessment, including medical, nursing, mental, and psychosocial needs, and must be developed within seven days after completion of the comprehensive MDS assessment. It also requires that all triggered Care Area Assessments (CAAs) and other factors identified by the IDT or resident preferences be incorporated into the plan of care. For one resident, R44, the clinical record showed physician orders for Haloperidol 10 mg by mouth twice daily for schizophrenia, along with orders for behavior monitoring and psychiatric medication side effect monitoring. Despite these orders, the resident’s care plan dated 03/11/2026 did not include any care plan addressing antipsychotic medication use or its indication. The MDS Coordinator stated that all residents receiving antipsychotic treatment should have a comprehensive care plan in place beginning with the date the medication was originally ordered, and upon review of the record confirmed that such a care plan was not present for this resident at the time of the survey. For another resident, R3, the care plan dated 03/13/2026 identified a problem of an indwelling catheter secondary to neurogenic bladder related to prostate cancer, with goals including remaining free from catheter-related trauma. The listed interventions included positioning the catheter bag and tubing below bladder level, monitoring and documenting intake and output per policy, and monitoring for pain, discomfort, and signs and symptoms of UTI. However, the care plan did not address the amount of water in the catheter balloon, use of a leg strap or securement device, or other securement measures. Physician orders specified checking a leg strap every shift and documented that the resident was admitted with an 18F catheter attached to a bedside drainage bag, but observations showed the Foley catheter positioned under the resident’s leg without a leg strap or securement device on two occasions, and a CNA reported being unaware that a leg strap was required. The MDS Coordinator confirmed that these ordered interventions were missing from the care plan.
Failure to Revise Care Plan for Ongoing Smoking Policy Noncompliance
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive care plan to reflect current interventions implemented in response to ongoing noncompliance with the facility’s non‑smoking policy. The facility’s policy requires that the comprehensive care plan be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment, and that it include measurable objectives, timeframes, and alternative interventions as needed, with qualified staff notified when changes are made. The resident’s care plan included a focus on resistiveness to care and noncompliance with smoking, noting that the resident continued to go outside beyond facility property to smoke, and an intervention to review the smoking policy with the resident. Another care plan focus identified the resident as a smoker requiring supervision while smoking, with interventions stating the resident required supervision while smoking and that the charge nurse should be notified if a smoking policy violation was suspected. Despite repeated and ongoing noncompliance with the non‑smoking policy, the care plan was not revised to include additional interventions that were actually implemented. These unreflected interventions included daily room searches for smoking paraphernalia, placement of a smoke detector in the resident’s room, relocation of the resident’s room closer to the nursing station, every‑two‑hour visual rounds to check for smoke, nursing checks upon return from outings, initiation of a Patient at Risk (PAR) process for vaping noncompliance, and issuance of a 30‑day discharge notice for repeated violations of the non‑smoking policy. Documentation on the Smoking Materials Monitoring Form showed initials on selected days only, indicating daily room searches were not consistently completed and documented for the entire month. The PAR Smoking Tracking form documented multiple observations of vaping in the room, repeated room checks, removal of vapor devices, and the resident’s refusal to comply with facility policies, with later weeks lacking IDT signatures and documentation, while the PAR Grid showed multiple prior entries for violating the non‑smoking policy.
Failure to Control Smoking and Vaping Hazards for a Noncompliant Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision for a resident with a known history of noncompliance with the facility’s non‑smoking policy. The facility’s Smoking Policy requires that residents not be allowed to keep cigarettes, cigars, pipes, matches, or lighters in their possession or rooms, and that non‑compliant smokers receive daily searches with documentation, while compliant smokers receive weekly searches. The policy also requires incident reports and review in a “Patients at Risk” process whenever smoking materials are found. Despite these written procedures, the resident’s Smoking Materials Monitoring Form for April showed multiple days without documented searches, indicating that required daily room searches were not consistently completed or recorded. The resident at issue was cognitively intact, with a BIMS score of 15, and had significant physical impairments including hemiplegia and hemiparesis on the left side, use of a manual wheelchair, and other neurologic and psychiatric diagnoses such as cerebral aneurysm, cerebral infarction, major depressive disorder with psychotic symptoms, PTSD, and speech and language deficits. The care plan identified the resident as resistive to care and noncompliant with smoking, noting that he continued to go outside beyond facility property to smoke, and also identified him as a smoker requiring supervision while smoking. Progress notes and Patient at Risk documentation showed a pattern of repeated violations of the non‑smoking policy, including multiple instances of vaping and smoking in his room, with staff repeatedly finding vape devices and other smoking paraphernalia in his possession and in his room. Throughout the period reviewed, staff observations and interviews confirmed ongoing noncompliance with the smoking policy and inconsistent implementation of the facility’s own interventions. Staff documented several occasions when the resident was observed vaping or smoking in his room, including in the presence of a state surveyor, and room searches revealed multiple vape devices hidden under the sheets. Staff interviews indicated that daily room checks were not always performed due to competing demands, that logs of every‑two‑hour rounds were not maintained, and that there was confusion or inconsistency regarding whether the resident could keep items such as air freshener at bedside. The social worker, Infection Preventionist, MDS coordinator, Activities Director, CNA, and Administrator all acknowledged that the resident’s room had to be searched for cigarettes and vaping paraphernalia and that prohibited items were repeatedly found, while documentation showed gaps in the required daily searches and incomplete follow‑through on the Patient at Risk tracking process. These actions and inactions resulted in the environment not being kept free from accident hazards as required by the facility’s policy and regulatory standards. The deficiency is further supported by the facility’s own records showing repeated entries on the Patient at Risk grid for violations of the non‑smoking policy over an extended period, as well as narrative notes describing the resident’s statements that he would continue to vape in his room and would simply obtain new devices if they were confiscated. Despite the known pattern of behavior and the facility’s policy requiring close supervision, daily searches, and thorough documentation for non‑compliant smokers, the monitoring forms and staff interviews demonstrate that these measures were not consistently carried out. The presence of multiple vape devices and cans of air freshener at the bedside during surveyor observations, along with staff acknowledgment that room checks were missed and that logs of frequent rounds were not kept, illustrate the facility’s failure to effectively implement its own safety procedures to prevent accident hazards related to smoking and vaping in the resident’s room.
Unlocked and Unattended Treatment Cart with Topical Medications
Penalty
Summary
Surveyors identified a deficiency related to medication storage when a treatment cart containing topical medications was left unlocked and unattended in a hall. The facility’s policy titled “Medication Storage in the Facility,” effective 10/01/2025, states that the medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff lawfully authorized to administer medications, and that medication rooms, carts, and supplies are to be locked or attended by authorized personnel. During an observation on 04/29/2026 at 9:35 AM, after wound care was provided to resident R3 by the wound care LPN, the treatment cart was observed left in the [NAME] hall across from R3’s room, unlocked and unattended for 30 minutes. In an interview, the wound care LPN confirmed that the treatment cart had been left unlocked and unattended. The Infection Preventionist LPN later confirmed that the wound care nurse told her the cart was left unlocked, and the Administrator stated that her expectation was that all medications, including topical medications, be locked when not in sight of a licensed nurse or authorized person. This deficient practice occurred in a facility with a census of 94 residents and involved the failure to follow the facility’s own policy requiring that medication carts be locked or attended by authorized personnel, resulting in unsecured access to topical medications on the treatment cart.
Failure to Implement Legionella Water Management and Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to provide and implement an infection prevention and control program, including a documented water management plan for Legionella and other waterborne pathogens, and a fully implemented Enhanced Barrier Precautions (EBP) program. The Administrator stated there was no Legionella water program in place, and the Maintenance Supervisor reported he was unaware of the requirement for such a program. This was despite the existence of a written Legionella Water Management Program policy, revised in September 2022, which described the need for an interdisciplinary water management team, detailed water system diagrams, identification of risk areas and situations for Legionella growth, control measures, monitoring systems, and annual review. Interviews confirmed that the expectation was that the facility would be conducting this water program, but it was not being done. The facility also failed to implement EBP for residents with indwelling medical devices and other risk factors, as required by its own policy. One resident with Alzheimer’s disease, urinary obstruction, and emphysema had an indwelling urinary catheter documented in the care plan and physician orders, but the care plan did not address EBP related to the catheter, and there was no order for EBP in the record. During catheter-related care, a CNA wore gloves but did not wear a gown, and there was no EBP signage or PPE setup at the room. Multiple staff members, including CNAs and a housekeeper who regularly worked on the resident’s hallway, reported they did not know what EBP was or incorrectly associated EBP only with residents on Transmission-Based Precautions. The DON acknowledged that an attempt to roll out EBP months earlier had not been completed, and that expected signage and PPE caddies for EBP were not fully in place. Additional infection control lapses were observed during tube feeding care and contact isolation. A resident receiving continuous tube feeding had a care plan and physician’s order for enteral nutrition, and an LPN initiated the feeding while wearing gloves but no gown. During the procedure, the LPN repeatedly touched her hair with the same gloved hands and then handled the feeding tube, pump, and syringe used to inject air and check residuals, only removing gloves and using hand sanitizer at the end. The LPN later acknowledged she should have changed gloves after touching her hair and stated she did not know what EBP was or that a gown was required for feeding tube care, while another LPN and the IP stated that EBP with gown and gloves should be used for feeding tube care and that staff should not touch their hair during care without changing gloves and performing hand hygiene. For a resident with a positive urine culture and a subsequent positive C. difficile culture who was on isolation, the door sign indicated isolation but did not provide instructions for visitors on required precautions or direct them to staff for guidance. The IP confirmed there was no system to direct visitors about PPE use for residents on contact isolation and acknowledged that visitors would not know to wear PPE if it was simply present in or on the door of the room. Overall, the survey findings show that the facility did not operationalize its written Legionella water management policy and did not consistently apply its EBP policy for residents with indwelling devices or wounds. Staff interviews and observations demonstrated a lack of knowledge and implementation of EBP, incomplete use of PPE during high-contact care activities such as catheter care and tube feeding, and unclear isolation signage that did not instruct visitors on appropriate precautions. These combined inactions and omissions in policy implementation, staff education, and practice led to the cited infection prevention and control deficiency.
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