Parkside Center For Nursing And Rehab At Ellijay
Inspection history, citations, penalties and survey trends for this long-term care facility in Ellijay, Georgia.
- Location
- 1362 South Main Street, Ellijay, Georgia 30540
- CMS Provider Number
- 115683
- Inspections on file
- 17
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Parkside Center For Nursing And Rehab At Ellijay during CMS and state inspections, most recent first.
Improper Insulin Pen Administration: An LPN failed to prime an insulin pen before giving NovoLog to a resident with DM2 and immediately removed the needle after injection. The resident had an order for sliding-scale insulin based on blood glucose, and the facility policy required priming the pen and holding it in place for several seconds to ensure the full dose was delivered.
A resident with pneumonia, pleural effusions, acute respiratory failure, COPD, and CHF received O2 at a higher flow rate than ordered. The physician ordered 2 LPM via NC, but surveyors observed the concentrator set at 3.5 LPM on multiple occasions. An LPN confirmed the incorrect setting and said she did not know who changed it; the DON stated oxygen is a medication and must be given per the physician’s order.
Medication administration errors exceeded the allowed rate when surveyors identified 2 errors in 31 observed opportunities. An LPN gave a 6:00 AM Protonix dose that had already been documented as administered and did not give ordered calcium carbonate 600 mg because only a 500 mg strength was available; the MAR also lacked documentation that the medication issue had been addressed. The DON stated nurses are expected to give medications as ordered and contact the provider if the correct dose is not available.
A resident received a roommate’s bedtime meds during the PM med pass, including insulin, melatonin, sertraline, ferrous sulfate, gabapentin, hydroxyzine, metoprolol, oxybutynin, and ranolazine. The resident had multiple chronic conditions, including HF, Afib, HTN, asthma, and cognitive communication deficit, with a BIMS of 13. The facility’s policy required photo identification in the MAR and verification of the six rights, but the wrong resident was medicated.
Failure to follow EBP and disinfect shared equipment occurred during medication passes when an LPN entered a resident’s room, donned a gown after reading EBP signage, but did not sanitize a blood pressure machine after use. The same LPN later used an unclean glucometer for two residents without disinfecting it between checks. In a separate observation, an RN administered meds via a PEG tube to a resident with EBP signage posted but did not wear PPE and stated she was unsure why the sign was present or whether PPE was needed.
The facility failed to provide written transfer notices to three residents and/or their representatives during emergent hospital transfers. The residents, with varying medical conditions and cognitive statuses, were transferred without receiving documentation explaining the reason for transfer. Staff interviews confirmed that discharge summaries were not provided in a language the residents or their representatives could understand.
A resident with hypoxemia and shortness of breath requiring intermittent oxygen therapy was admitted, but the facility failed to include oxygen use in the comprehensive care plan. Interviews with an LPN, MDS Coordinator, and DON confirmed the oversight, acknowledging that the care plan should have detailed the oxygen use to inform staff of the resident's needs.
A resident did not receive most of her prescribed medications due to a delay in pharmacy delivery and a lack of timely action by the facility staff. The resident, with multiple health conditions, was admitted without her medications being entered into the system in time for delivery. The facility had options to access medications from an emergency kit or request a stat delivery, but these were not utilized. Communication issues also contributed to the delay, as medications were delivered to the wrong unit.
A facility failed to document target behaviors for a resident prescribed lorazepam for anxiety, potentially leading to unnecessary medication use. Despite the facility's policy requiring documentation of psychotropic drug use, there was no evidence of monitoring the resident's behaviors to justify the medication. Staff interviews confirmed the lack of expected documentation.
Improper Insulin Pen Administration
Penalty
Summary
The facility failed to ensure professional standards were followed when preparing and administering insulin for one resident receiving NovoLog by insulin pen. The resident had diagnoses including type 2 diabetes mellitus and an order for NovoLog subcutaneously with meals using a sliding scale based on blood glucose readings. During an observed medication pass, the LPN checked the resident’s blood sugar at 195 mg/dL and prepared 14 units of insulin, attached the pen needle, and dialed the ordered dose. The LPN did not prime the insulin pen before administration, despite the facility policy requiring priming prior to each use. She administered the insulin in the resident’s right arm and immediately removed the needle from the skin after fully depressing the plunger. In a follow-up interview, the LPN stated she was not aware the pen should be wasted prior to administration or that the needle should remain in the skin for several seconds after injection. The DON stated nurses were expected to follow the facility’s insulin pen policy and hold the pen against the skin for five to 10 seconds after pressing the injection button to ensure the full dose is delivered.
Oxygen Flow Rate Not Set Per Physician Order
Penalty
Summary
Oxygen therapy was not administered according to the physician’s order for one resident receiving O2. The resident was admitted with diagnoses including pneumonia, pleural effusion, acute respiratory failure, COPD, and CHF. The admission MDS documented a BIMS score of 14 and indicated the resident was on oxygen therapy. The care plan for COPD included administering oxygen as ordered, and the physician order dated 03/03/2026 directed O2 at 2 LPM via nasal cannula. Observations on 03/03/2025 at 10:37 AM, 2:53 PM, and 03/04/2025 at 9:45 AM showed the oxygen concentrator set at 3.5 LPM via nasal cannula. The assigned LPN confirmed the flow rate was 3.5 LPM and then verified the order was for 2 LPM, stating she did not know who had adjusted it. The DON stated oxygen is considered a medication and must be administered according to the physician’s order, and that nurses are responsible for ensuring physician orders and care plans are followed.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure a medication error rate of less than five percent. During observations, record review, staff interviews, and review of the facility’s Medication Administration policy, surveyors identified 2 medication errors out of 31 opportunities observed, resulting in a 6.45 percent medication error rate. The policy required staff to follow the six rights of medication administration, including the right dosage and right time, and to compare the medication source with the EMAR to verify the resident name, medication name, form, dose, route, and time. An LPN was observed administering 9:00 AM medications to a resident and included a 6:00 AM dose of Protonix from the blister pack even though it had already been documented as administered in the EMR. The LPN stated she did not realize it had already been given and assumed it was due because it appeared as an AM medication on the blister pack card. The same LPN also did not administer calcium carbonate 600 mg because only calcium carbonate 500 mg was available and she could not locate the correct strength. Later review showed the calcium carbonate had still not been documented as administered, and there was no documentation that the pharmacy had been contacted or the physician notified. The DON stated nurses are expected to administer medications as ordered, and if the correct dosage is not available, the provider should be contacted for further instructions.
Medication Admin Error: Resident Received Roommate’s Medications
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when the resident received another resident’s bedtime medications during the 9:00 PM medication pass. The medications mistakenly administered included Tresiba insulin 8 units subcutaneously, Humalog insulin per sliding scale with 4 units given, melatonin 3 mg two tablets, sertraline 50 mg, ferrous sulfate 325 mg, gabapentin 300 mg, hydroxyzine 25 mg, metoprolol succinate ER 25 mg one-half tablet, oxybutynin 2.5 mg, and ranolazine ER 500 mg. The error involved medications intended for the resident’s roommate and was identified as a self-reported incident. The affected resident had diagnoses including rheumatoid arthritis, hypertension, heart failure, atrial fibrillation, pulmonary hypertension, asthma, peripheral vascular disease, lymphedema, morbid obesity, generalized weakness, and cognitive communication deficit. The quarterly MDS indicated adequate hearing, ability to make self understood, ability to understand others, and a BIMS score of 13, indicating little to no cognitive impairment. The resident’s active medication profile included multiple medications such as anticoagulants, antibiotics, diuretics, inhalers, and other routine therapies, but no reference to insulin in the resident’s high-risk medication section. The facility’s policy required staff to identify residents by photo in the MAR, follow the six rights of medication administration, and compare the medication source with the EMAR to verify the resident’s name, medication name, form, dose, route, and time. The nurse involved in the incident was identified by the facility as RN FF, who recognized the error immediately and reported it to the physician and family. The physician evaluated the resident the next day, and the record noted that the resident’s blood glucose remained stable with no documented hypoglycemia.
Failure to Follow EBP and Disinfect Shared Equipment
Penalty
Summary
The facility failed to consistently implement enhanced barrier precautions (EBP) and failed to sanitize shared medical equipment between resident uses during medication administration observations. Review of the facility policies showed that reusable, non-critical equipment such as blood pressure machines and glucometers were to be cleaned and disinfected after each use, and that EBP was required for residents with wounds or indwelling medical devices during high-contact care activities, including device care or use. During an observation with an LPN, the nurse entered a resident’s room to check blood pressure after reading the EBP sign, donned a gown, and stated she believed she was required to gown every time she entered the room. She brought a blood pressure machine into the room, obtained the resident’s blood pressure, and left without sanitizing the machine. When questioned, she stated she did not think cleaning was necessary because she was unsure what condition the resident had and believed the roommate, not the resident she was caring for, likely had the condition; she then acknowledged the blood pressure machine should have been cleaned. The same LPN later checked one resident’s blood sugar, placed the glucometer on the resident’s bed, exited the room to obtain insulin, and returned the glucometer to the medication cart without sanitizing it. She then used the same unclean glucometer for another resident’s blood sugar check and again returned it to the cart without cleaning it. In a separate observation, an RN administered medications via a PEG tube to a resident with EBP signage posted on the door, performed hand hygiene, but did not wear PPE during the procedure. The RN stated she was not sure why the signage was present and was unsure whether PPE should have been used for PEG tube medication administration. The IC Nurse and DON stated that staff were expected to sanitize shared equipment between residents and follow EBP practices.
Failure to Provide Required Transfer Notices
Penalty
Summary
The facility failed to provide written transfer notices containing all required information to three residents and/or their representatives during emergent hospital transfers. This deficiency was identified through record reviews, resident and staff interviews, and facility policy review. The facility's policy on transfer and discharge was not followed, as it required providing orientation for transfer or discharge in a manner the resident could understand and sending copies of notices for emergency transfers to the Ombudsman. However, for the residents in question, there was no documentation of a written notice of transfer provided to them or their representatives. Resident 8, with a diagnosis of gastrointestinal hemorrhage and moderately impaired cognition, was transferred to the emergency department due to dyspnea and blood in stool without receiving a written notice. Resident 18, with little or no cognitive deficit, was transferred due to fecal impaction without a written notice. Resident 91, with multiple diagnoses including dementia and heart failure, was transferred after the resident's daughter called 911, and no written notice was provided. Interviews with the Administrator, Unit Manager, and Director of Nursing confirmed that discharge summaries were not provided in a language the residents or their representatives could understand, and a separate discharge sheet indicating the reason for discharge was not available.
Oxygen Use Omitted from Resident's Care Plan
Penalty
Summary
The facility failed to include the use of oxygen in the comprehensive care plan for one resident, identified as R20, who was part of a sample of 23 residents reviewed for care planning. The resident was admitted with diagnoses including hypoxemia and shortness of breath, requiring intermittent oxygen therapy. Despite these needs, the care plan initiated on 12/16/24 did not document the use of oxygen, which is essential for communicating the resident's care requirements to the staff. Interviews with facility staff, including an LPN, the MDS Coordinator, and the Director of Nursing, confirmed that oxygen should have been included in the care plan to ensure all nursing staff were aware of the resident's needs and how to properly administer care. The omission was acknowledged as an oversight, with staff indicating that the care plan should detail whether oxygen is used continuously or as needed (PRN).
Failure to Administer Medications Timely Due to Pharmacy Delivery Issues
Penalty
Summary
The facility failed to ensure timely administration of medications for a resident, identified as R91, due to a delay in receiving medications from the pharmacy. R91, who was admitted with multiple diagnoses including nonrheumatic aortic valve stenosis, idiopathic pulmonary fibrosis, and chronic respiratory failure, did not receive most of her prescribed medications ordered on 09/21/24. The medications were delivered to the facility on 09/20/24 but were not administered to the resident. The Director of Nursing (DON) confirmed that the orders were not entered prior to the resident's admission, and the pharmacy did not deliver medications on Sundays, which contributed to the delay. Interviews with the DON and nursing staff revealed that the facility had procedures in place to access medications from an emergency kit or request a stat delivery from the pharmacy, but these options were not utilized. The DON acknowledged that the charge nurse could have administered Lasix from the emergency kit, as it was available in the correct dosage. Additionally, there was a communication breakdown, as RN4 was not informed about the pending medication delivery, and medications intended for the rehabilitation side were mistakenly delivered to the long-term care side of the facility. The Medical Director expected nurses to access the emergency kit or contact the pharmacy for immediate delivery if necessary.
Failure to Monitor Antipsychotic Medication Use
Penalty
Summary
The facility failed to identify and document target behaviors for monitoring the effectiveness of antipsychotic medication for one resident, leading to potential unnecessary use of lorazepam. The facility's policy requires that psychotropic drugs are only given when necessary to treat a specific condition, with documented evidence of the medication's benefit to the resident. However, for Resident 48, there was no documentation of monitoring moods and behavioral symptoms to evaluate the need for lorazepam, which was prescribed for anxiety. Resident 48 was admitted with diagnoses including a history of falls, multiple fractures, panic attacks, anxiety, and major depression disorder. Despite having a BIMS score indicating little or no cognitive deficit, there was no evidence in the medical records of monitoring the resident's behaviors to justify the administration of lorazepam. Interviews with staff revealed that the expected documentation of behaviors in the Medication Administration Records was not present, and the Director of Nursing confirmed that behaviors should be documented with each administration of the 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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