Pruitthealth - Austell
Inspection history, citations, penalties and survey trends for this long-term care facility in Austell, Georgia.
- Location
- 1700 Mulkey Rd, Austell, Georgia 30106
- CMS Provider Number
- 115314
- Inspections on file
- 24
- Latest survey
- December 5, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Pruitthealth - Austell during CMS and state inspections, most recent first.
Two residents experienced deficiencies in care planning and implementation. One resident, with significant mobility impairments, was injured during a transfer when a CNA failed to provide hands-on assistance or use a gait belt as required by the care plan. Another resident, with multiple limb amputations and cognitive impairment, was unable to access the call light due to lack of appropriate care plan interventions and staff not ensuring the device was within reach. These failures resulted in actual harm and unmet needs.
Two residents requiring oxygen therapy did not receive care in accordance with physician orders and facility policy: one received oxygen at a lower flow rate than ordered, and another was administered oxygen without any physician order in place. Observations confirmed the discrepancies, and staff interviews revealed a lack of adherence to protocols for verifying and following oxygen orders.
Surveyors identified that two medication errors occurred when a nurse administered an incorrect dose of Omega-3 and failed to measure and apply Voltaren gel as ordered for a resident. The nurse did not use a measuring tool for the topical medication and omitted application to one area, resulting in a medication error rate above the acceptable threshold.
Surveyors found that two medication carts contained expired ophthalmic drops, a soiled nutritional supplement with an unreadable expiration date, and loose, unlabeled pills and capsules. Additionally, the controlled substance record book had unsecured, torn pages. Nursing staff were unable to identify the loose medications or their intended recipients, and facility policy requiring daily audits and proper medication storage was not followed.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
A resident’s family member paid for a private room with the understanding that other charges would be covered by Medicare and supplemental insurance, but was later billed for an excessive amount due to a billing error that charged for 484 days instead of 22. The bill was sent to collections before the error was identified, and a partial refund was eventually issued, but not in a timely manner.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as required by their care plan.
A resident with right-sided hemiplegia and dependence on staff for transfers was transported by a family member without receiving education or supervision from facility staff on safe transfer techniques, despite being at risk for falls. Facility staff confirmed there was no policy or training provided for such situations.
A resident who was cognitively intact was transported by facility staff to a medical appointment but was not picked up by the facility afterward. Due to a delay and a staff member's shift ending, the resident's son was asked to bring her back, resulting in the resident experiencing leg pain during the return trip. The facility did not have a transportation policy in place.
A resident's clinical records were found to be incomplete, with multiple instances of missing documentation for the administration of prescribed medications such as Hiprex, gabapentin, and carvedilol. Facility policy and the DON confirmed that nurses are expected to document all medication administration, but records showed several undocumented doses, raising concerns about the accuracy of care provided.
The facility failed to maintain the required operating temperature for the dishwashing machine, potentially affecting 114 residents. Observations and interviews revealed that the machine did not consistently reach the necessary temperatures for washing and rinsing, and staff were unaware of the required temperature levels. Temperature logs showed inconsistencies, with several instances of recorded temperatures below the required 120 degrees Fahrenheit.
A resident with intact cognition and significant physical impairments was left unclothed and uncovered by a CNA during care, following a disagreement about scheduling assistance. The resident reported feeling neglected and isolated, with delays in call light responses and inconsistent care. Staff interviews confirmed the incident and highlighted the resident's specific care needs.
The facility failed to provide a safe, clean, and homelike environment, with deficiencies observed in six rooms across two halls. Issues included dirty and damaged bathroom exhaust fan vent covers, PTAC units, low water pressure in a bathroom sink, damaged hallway handrails, and a strong odor in the west wing. The Environmental Services Director noted maintenance staff clean filters monthly, but there was uncertainty about recent cleaning due to construction. The facility lacked a formal Maintenance or Environmental policy, and the maintenance logbook showed no recorded issues, indicating a lack of documentation and communication.
A resident expressed concerns about persistent odors from a roommate's area, affecting his quality of life and ability to enjoy meals. Despite reporting the issue to several staff members, no grievance was filed. Staff attempted to offer alternatives, but the resident declined. Interviews revealed a lack of adherence to the facility's grievance policy, with the Unit Manager not considering the issue serious enough and the Wound Care Nurse unaware due to being on vacation. The grievance log showed no documentation of the complaint.
The facility failed to provide adequate assistance with ADLs for two residents. One resident, with multiple sclerosis, was observed unkempt and with a strong urine smell, indicating a lack of grooming and personal hygiene care. Despite needing substantial assistance, her fear of the mechanical lift was misinterpreted as a refusal of care, leading to missed showers. Another resident, severely cognitively impaired, was observed with long facial hair, suggesting a lack of grooming. The facility lacked specific policies for ADLs and grooming, contributing to these deficiencies.
The facility failed to document and administer pain medication for two residents, leading to potential risks for medical complications and diminished quality of life. One resident experienced an unwitnessed fall and was given Tylenol without proper documentation, while another resident missed several doses of prescribed pain medication due to unavailability.
A resident with a history of fractures fell during a transfer using a mechanical lift due to the use of an incorrect size sling, which resulted in a strap breaking. Staff involved were aware of the incorrect sling size but proceeded with the transfer, leading to the resident's fall. The resident expressed fear of using the lift again, and the resident's daughter raised concerns about the care provided.
A facility failed to disinfect reusable equipment and perform hand hygiene during medication administration, affecting five residents. An RN and an LPN used an electronic blood pressure cuff on multiple residents without disinfecting it between uses. The RN also did not consistently perform hand hygiene when moving between residents' rooms. The Director of Health Services confirmed the expectation for equipment disinfection to ensure resident safety.
The facility failed to administer medications per physician orders and within the required time frame for three residents, resulting in an 80.7% medication error rate. Medications were often given late, and one resident did not receive a prescribed nasal spray.
The facility failed to promptly and thoroughly resolve resident grievances regarding missing laundry, despite multiple complaints and policies in place. Observations revealed multiple bags of unclaimed clothing, and interviews confirmed ongoing issues with missing items. The Environmental Services Director acknowledged problems with labeling, and the Administrator confirmed that the issue was still being addressed.
A resident with multiple medical conditions reported that money was missing from her debit card. The facility's investigation revealed that a CNA had used the resident's debit card without proper consent, leading to the CNA's termination and the return of the misappropriated funds. Interviews confirmed that the CNA violated facility policy by accepting and using the resident's debit card.
A resident with multiple diagnoses, including multiple sclerosis and functional quadriplegia, fell during a shower due to the facility's failure to provide the required two-person assistance. Despite the resident's total dependence on two or more persons for physical assistance, only one CNA was present, leading to the fall. Interviews and records confirmed the incident and the facility's non-compliance with its fall occurrence reduction policy.
The facility failed to lock medication and treatment carts when unattended, as observed in two medication carts and one treatment cart. Staff interviews confirmed that carts should be locked, but multiple instances of unlocked carts were noted, placing residents, staff, and visitors at risk.
Failure to Develop and Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, resulting in deficiencies related to transfer assistance and call light accessibility. One resident, with a history of right tibial shaft fracture, morbid obesity, generalized muscle weakness, and lack of coordination, experienced a fall and injury during a transfer from bed to wheelchair. The resident, who was cognitively intact and non-weight-bearing on the right leg, requested assistance from a CNA. The CNA did not provide hands-on assistance or use a gait belt, instead attempting to grab the resident's loose pants, which failed to prevent the fall. The resident sustained a laceration to the right knee and a head injury, requiring hospital transfer. The care plan for this resident included interventions for fall risk and assistance with transfers, but these were not adequately implemented by staff during the incident. Another resident, with multiple limb amputations and moderate to severe cognitive impairment, required total assistance for all activities of daily living. The care plan for this resident did not address the inability to use upper extremities to activate the call light, despite documentation that the call light should be kept within reach at all times. Observations revealed that the call light was frequently placed out of reach, and the resident was unable to summon assistance independently. The resident reported having to call out loudly for help, and staff confirmed the call light was not reliably accessible. The care plan failed to include specific interventions or adaptive equipment to address the resident's unique needs for call light access. These deficiencies were identified through observations, staff and resident interviews, and record reviews, which demonstrated that the facility did not ensure care plans were comprehensive, measurable, and tailored to the residents' individual needs. The lack of proper implementation and documentation of care plan interventions led to actual harm in one case and placed another resident at risk of unmet needs.
Failure to Administer Oxygen as Ordered and Without Physician Order
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents who required oxygen therapy. For one resident with diagnoses including COPD, chronic respiratory failure with hypoxia, and heart failure, the physician's order specified oxygen at 2 liters per minute (LPM) via nasal cannula continuously. However, observations on multiple occasions revealed that the oxygen concentrator was set below the ordered rate, at 1.5 LPM and under 2 LPM. The LPN confirmed the setting was incorrect and adjusted it only after being prompted during the survey. For another resident with chronic respiratory failure, COPD, and heart disease, there were no physician orders for oxygen therapy in the electronic medical record prior to the survey, despite the resident being observed wearing oxygen at 2 LPM via nasal cannula on two separate occasions. The LPN was unable to locate any oxygen orders after searching the record and could not explain the basis for administering oxygen. The care plan for this resident did not address respiratory conditions until the deficiency was identified during the survey, at which point a problem of COPD was added and an order for oxygen was obtained. Facility policy required that oxygen be administered only with a physician's order and at the prescribed flow rate, and both the Administrator and DON confirmed that staff are expected to follow these orders. The failure to administer oxygen at the correct setting for one resident and to ensure a physician's order was in place for another constituted a deficiency in respiratory care, as staff did not adhere to established protocols and physician instructions.
Medication Administration Errors Result in Elevated Error Rate
Penalty
Summary
Surveyors observed that the facility failed to ensure accurate administration of medications, resulting in a medication error rate of 7.14% during the review period. Specifically, two medication errors were identified out of 28 opportunities observed. One error involved a nurse administering only one capsule of Omega-3 (fish oil) to a resident, despite the physician's order for two capsules to be given orally twice daily. In the same observation, the nurse dispensed Voltaren Arthritis Pain (diclofenac sodium) gel by squeezing an unmeasured amount into a medication cup and applied it only to the resident's shoulders, omitting the lower back as specified in the physician's order. The nurse did not use a measuring tool to ensure the correct 2-gram dosage and was unaware of the specified amount in the electronic record. Interviews with facility staff confirmed that the expectation is for medications to be administered exactly as ordered by the physician. The nurse involved acknowledged not referencing a specific dosage for the topical medication, and both the Administrator and Director of Nursing reiterated the facility's policy of zero tolerance for medication errors and the requirement for staff to follow all physician orders precisely.
Deficient Medication Storage and Labeling Practices
Penalty
Summary
Surveyors observed that the facility failed to ensure medications and biologicals were stored in a safe and secure manner on two of five medication carts. On one cart, two expired ophthalmic drops were found, along with a nutritional supplement bottle that was soiled, stored in a bag with a crystallized substance, and had an expiration date that was no longer visible. Additionally, a loose, unlabeled pill and capsule were discovered in the medication drawer. The controlled substance record book on this cart had multiple pages that were torn, loose, and no longer secured within the binder, creating a risk for inaccurate or incomplete controlled substance accountability. On a second medication cart, another loose, unlabeled capsule was found in the medication drawer. Nurses interviewed during the survey were unable to identify the loose medications or determine which residents they were prescribed to. The facility's policy requires nurses to check all medications for expiration and deterioration before administration, maintain clean and organized medication carts, and complete daily audits to remove outdated, contaminated, or deteriorated medications. However, these procedures were not followed, as evidenced by the presence of expired medications, soiled supplements with unreadable expiration dates, and loose, unidentified pills. Interviews with nursing staff and facility leadership confirmed the findings, acknowledging that expired medications and supplements should not be administered and that loose, unidentified medications could result in residents not receiving their prescribed medications. The presence of unsecured pages in the controlled substance record book was also confirmed, with staff noting that this could result in medications not being administered properly or according to orders. The facility's expectations were reiterated by the administrator, who stated that nursing staff are responsible for ensuring expired medications are not present and that medication carts remain clean and free of loose pills.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations.
Failure to Ensure Accurate Billing and Timely Refunds for Private Room Charges
Penalty
Summary
The facility failed to ensure accurate billing and timely refunds for a resident who was admitted and later discharged after a short stay. The resident’s family member requested a private room and paid $3,720 as requested by the facility, with the understanding that all other charges would be covered by Medicare and supplemental insurance. Despite this, the family member later received a bill for over $56,000, reflecting an erroneous charge for 484 days of private room care, when the actual stay was only 22 days. The family member contacted the facility multiple times regarding the excessive bill. Upon review, the Business Office Manager confirmed that a billing entry error had occurred, resulting in the resident being billed for far more days than were actually provided. Documentation showed that the bill was sent to collections for the unjustified amount. Eventually, a partial refund of $992 was issued to the resident. The facility’s admission agreement stated that overpayments would be refunded as soon as possible after insurance claims were verified and paid, but the refund was not provided in a timely manner.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
A deficiency was identified when appropriate treatment and care were not provided according to physician orders, as well as the resident's preferences and goals. The report notes a failure to ensure that care was delivered in alignment with the established plan, which is required to meet the individual needs and wishes of the resident. This lapse resulted in the resident not receiving care as intended, based on their documented preferences and medical directives.
Failure to Provide Supervision and Family Training for Safe Resident Transfer
Penalty
Summary
A deficiency was identified when a resident, who was dependent on staff for transfers due to right-sided hemiplegia and had documented impairments in both upper and lower extremities, was not provided with adequate supervision or training for safe transfer from a wheelchair to a personal vehicle. The resident's care plan and physical therapy notes indicated she was at risk for falls and required staff assistance for all transfers. Despite this, after a medical appointment, the resident's son was responsible for transferring her into a car and transporting her back to the facility without any education or guidance from facility staff on how to perform the transfer safely. Interviews with facility staff confirmed that there was no policy in place regarding the transportation of residents by family members, and the Director of Rehabilitation stated that no education was provided to the family on safe transfer techniques due to the resident's condition. The lack of supervision and absence of family training for safe transfers created a situation where the resident was at risk for falls and injury during the transfer process.
Failure to Ensure Resident Return Transportation from Medical Appointment
Penalty
Summary
A cognitively intact resident, as indicated by a BIMS score of 14 out of 15, was admitted to the facility and required transportation to and from a medical appointment. The facility arranged for transportation to the appointment, but failed to ensure the resident was picked up afterward. Certified Nurse Aide (CNA) 2 confirmed leaving the resident at the appointment, expecting CNA1 to pick her up. CNA1 reported that due to a delay at the appointment and her scheduled end of shift, she informed the resident's son that she could not wait to return the resident to the facility. As a result, the resident's son transported her back, during which the resident reported being placed in the back of the car, causing leg pain. The facility administrator acknowledged there was no policy on transportation, but stated the expectation was for the facility to provide return transportation if it had provided the initial transport.
Incomplete Medication Administration Documentation
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate documentation for one resident. Review of the resident's electronic medical records and Medication Administration History (MAH) revealed multiple instances where administration of prescribed medications, including Hiprex, gabapentin, and carvedilol, was not documented on several dates across January, February, May, and June. The facility's policy requires medications to be administered as prescribed and documented accordingly, but the records showed missing documentation for both morning and evening doses on specific dates. Interviews and policy reviews confirmed that the expectation was for nurses to document medication administration as part of standard care. The Director of Nursing stated that documentation of administered medications is required. The lack of documentation in the resident's records had the potential to result in the resident not receiving accurate care, as there was no evidence to confirm whether the medications were given as ordered.
Dishwashing Machine Temperature Deficiency
Penalty
Summary
The facility failed to ensure that the dishwashing machine consistently reached the required operating temperature, which had the potential to affect 114 out of 117 residents receiving an oral diet from the kitchen. Observations revealed that the dishwashing machine did not consistently achieve the necessary temperatures for washing and rinsing, with recorded temperatures during three consecutive cycles being below the required levels. Kitchen staff were observed operating the dishwashing machine without knowledge of the required temperatures and chemical levels, as their primary responsibility had been food scrap removal, not machine operation. Interviews with the Dietary Manager and a Regional corporate representative acknowledged the temperature discrepancies. The facility's policy required the use of temperature indicator sticks or a waterproof thermometer to verify the internal temperature of the dishwashing machine, but the observations and temperature logs indicated inconsistencies. The temperature logs showed that the machine did not consistently reach the required temperature of 120 degrees Fahrenheit, with several instances of recorded temperatures at 118 degrees Fahrenheit or lower. The deficiency was identified through a combination of observations, interviews, and record reviews, highlighting a failure in maintaining proper dishwashing machine temperatures.
Resident Left Unclothed and Uncovered During Care
Penalty
Summary
The facility failed to ensure a resident's right to dignity, as evidenced by an incident involving a resident, R41, who was left unclothed and uncovered during care. R41, a quadruple amputee with intact cognition, reported that a CNA became upset when she requested assistance at a specific time for a Valentine's Day party. The CNA allegedly threw one of R41's prosthetic legs at the wall and left her naked and uncovered. This incident was reported to the facility, and interviews confirmed that the resident was left in this state. Further interviews revealed that R41 felt neglected and isolated following the incident, with delays in response to her call light and inconsistent care from staff. The resident expressed feeling targeted after filing a complaint about the CNA's neglect. Staff interviews indicated that R41 was not difficult but required specific care due to her condition, including dedicated time for getting up and bathroom breaks. The Director of Healthcare Services and the Administrator both stated that it was the responsibility of all staff to answer call lights and ensure residents' privacy and dignity.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for residents, as evidenced by several deficiencies observed in six of 64 rooms across two of four halls. Observations revealed dirty and damaged bathroom ceiling exhaust fan vent covers, dirty and damaged PTAC units, a bathroom sink with low water pressure, damaged hallway handrails, and a strong pungent odor in the west wing hallways. These issues were confirmed during interviews and walking rounds with the Administrator, Environmental Services Director (ESD), and Maintenance Director (MD). The ESD noted that maintenance staff were responsible for cleaning filters monthly, but there was uncertainty about whether this had been done recently due to ongoing construction work. Additionally, the ESD mentioned that certain rooms required more frequent cleaning due to persistent odors. The facility lacked a formal Maintenance or Environmental policy, as confirmed by the Administrator, ESD, and MD. The maintenance logbook for the [NAME] Wing showed no recorded issues in the past month, indicating a lack of documentation and possibly communication regarding maintenance needs. The ESD stated that environmental issues were expected to be addressed promptly, but the absence of a structured policy and documentation system may have contributed to the oversight of these deficiencies. The Administrator acknowledged the need for immediate correction of the identified issues.
Failure to File Grievance for Resident's Roommate Odor Complaint
Penalty
Summary
The facility failed to file a grievance on behalf of a resident who expressed concerns about persistent odors coming from his roommate's area, particularly during activities of daily living care and wound treatment. The resident, identified as R47, reported that the smell was affecting his ability to enjoy meals and impacting his quality of life within the facility. Despite expressing these concerns to multiple staff members, including a Certified Medication Aide, a Certified Nursing Assistant, and a Unit Manager, no grievance was filed on his behalf. The staff members attempted to accommodate the resident by offering alternatives such as eating in the dining room, but the resident declined these offers. Interviews with staff revealed a lack of understanding or adherence to the facility's grievance policy. The Unit Manager did not consider the issue serious enough to warrant filing a grievance, and the Wound Care Nurse was unaware of the complaint due to being on vacation. The Director of Health Services and the Administrator were also unaware of the resident's concerns, indicating a breakdown in communication and protocol adherence. The facility's grievance log showed no documentation of a grievance being filed for this issue, highlighting a failure to follow the established grievance procedures.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for two residents, R42 and R106. Resident R42, who has multiple sclerosis and other health issues, was observed to have unkempt hair, facial hair, and a strong urine smell, indicating a lack of grooming and personal hygiene care. Despite her care plan requiring substantial assistance with ADLs, including showers and grooming, R42 reported that she was afraid of the mechanical lift used for transfers, which staff misinterpreted as a refusal of care. Documentation showed inconsistencies in her bathing schedule, with several missed shower days. Resident R106, who is severely cognitively impaired, was also observed with long facial hair, suggesting a lack of grooming. Despite needing substantial assistance with personal hygiene, there was no evidence of grooming being provided. Interviews with staff revealed that if a resident refused a shower, a bed bath was offered, and refusals were documented. However, the facility lacked specific policies for ADLs and grooming, contributing to the deficiencies observed.
Failure to Document and Administer Pain Medication
Penalty
Summary
The facility failed to document the administration of pain medication on the electronic Medication Administration Record (eMAR) and follow up on the assessment related to a fall for one resident, and to reorder or follow up on the delivery of pain medications for another resident. This deficiency had the potential to place the residents at risk for medical complications, unmet needs, and a diminished quality of life. Resident R97, who was admitted with diagnoses including muscle weakness and type 2 diabetes mellitus, experienced an unwitnessed fall in the bathroom. The resident was on a scheduled pain medication regimen and had a history of falls. After the fall, the resident was found with bruises and was given Tylenol for pain, but the administration was not documented on the eMAR. The nurse involved did not document the dressings applied to the resident's wounds and was unaware of how to access wound care assessment notes in the EMR. The nurse also failed to communicate the bleeding and dressing application to the nurse practitioner. Resident R23, admitted with fractures and functional limitations, was prescribed hydrocodone/acetaminophen for pain management. However, the resident did not receive the medication on several occasions due to it being unavailable. The facility's policy required medications to be reordered when the supply was low, but this was not adhered to, resulting in missed doses. The unit manager confirmed that no resident should go without pain medication, highlighting a lapse in medication management and ordering procedures.
Resident Fall Due to Incorrect Sling Size During Transfer
Penalty
Summary
The facility failed to ensure the safety of a resident during a transfer using a mechanical lift, resulting in an accident. The resident, who had a history of fractures and required assistance with activities of daily living, was being transferred from a wheelchair to a bed when the incident occurred. The staff used an incorrect size sling, which led to the breakage of a strap and caused the resident to fall to the floor. Interviews with the staff involved revealed that they were aware the sling was not the correct size but proceeded with the transfer due to a lack of alternatives. The resident, who had intact cognition, expressed fear and reluctance to use the mechanical lift following the fall. The resident's daughter, who is also the responsible party, voiced concerns about the care her mother was receiving and questioned how such an accident could occur. The Director of Health Services expected staff to use proper equipment and have two people assist with mechanical lifts, but this expectation was not met in this instance.
Infection Control Deficiency in Medication Administration
Penalty
Summary
The facility failed to properly disinfect reusable equipment and perform hand hygiene during medication administration, affecting five residents. During observations, a registered nurse (RN) used an electronic blood pressure cuff on multiple residents without disinfecting it between uses. The RN also failed to perform hand hygiene consistently when moving between residents' rooms. This practice was observed during medication administration for two residents, where the RN did not disinfect the blood pressure cuff after checking each resident's blood pressure and did not perform hand hygiene after administering medications. Similarly, a licensed practical nurse (LPN) was observed using the same electronic blood pressure cuff on two residents without disinfecting it between uses. The LPN acknowledged the failure to disinfect the equipment during an interview. The Director of Health Services confirmed that the expectation was for the blood pressure cuff to be disinfected between uses to ensure resident safety. The failure to adhere to proper infection control practices had the potential to spread microorganisms among residents.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to administer medications per physician orders and within the required time frame for three residents. Resident 21, who had diagnoses including sepsis, protein-calorie malnutrition, and acute kidney failure, did not receive their medications on time. The medications were administered at 10:43 am instead of the scheduled 9:00 am. Interviews with the resident and staff confirmed that medications were often given late, and the Director of Nursing acknowledged that medications should be administered within a one-hour window before or after the scheduled time. Similarly, Resident 18, with diagnoses including hypertension, morbid obesity, major depressive disorder, and liver disease, also received their medications late at 10:54 am instead of 9:00 am. An interview with the resident confirmed that medications were frequently late, and an observation during a medication pass revealed that an additional medication, guaifenesin, was administered without an order. Resident 27, who had acute respiratory failure and nasal congestion, did not receive their prescribed nasal spray during a medication pass. The Certified Medication Aide stated that the resident would request the saline mist when needed, but it was not offered to the resident as per the physician's order. The facility's medication error rate was found to be 80.7 percent, significantly higher than the acceptable rate of less than 5 percent. The facility's policy requires medications to be administered within 60 minutes before or after the scheduled time, but this was not adhered to, leading to the deficiencies observed during the survey.
Failure to Resolve Resident Grievances Regarding Missing Laundry
Penalty
Summary
The facility failed to ensure prompt and thorough efforts to resolve continued resident grievances regarding missing laundry. Despite having policies in place for handling grievances and missing items, the facility did not effectively address multiple complaints from residents about missing clothing. The grievance logs for 2023 and 2024 documented several instances where residents complained about missing clothing, and interviews with residents confirmed ongoing issues. One resident reported missing several pants and long sleeve shirts and stated that the Environmental Services Director had not been in contact about replacing those items. Another resident, the Resident Council President, confirmed that there were still issues with missing clothing and that the Environmental Services Director had been notified but had not resolved the issue. Observations of the laundry room revealed multiple bags of unclaimed resident clothing, indicating a systemic issue with the management of residents' laundry. The Environmental Services Director acknowledged problems with labeling residents' clothing and stated that unclaimed clothing was kept for 90 days before being donated to residents. The Administrator confirmed that the facility was still working on resolving the missing items issue. These findings indicate a failure to adhere to the facility's grievance policy and to take prompt and effective action to resolve residents' complaints about missing laundry.
Misappropriation of Resident's Funds by CNA
Penalty
Summary
The facility failed to protect a resident's right to be free from misappropriation of property by facility staff. The resident, who had multiple medical conditions including multiple sclerosis and functional quadriplegia, reported that money was missing from her debit card. The facility's investigation revealed that a Certified Nursing Assistant (CNA) had used the resident's debit card without proper consent. The resident had initially given the CNA her debit card to help with pregnancy-related expenses, but the CNA used more money than agreed upon. The CNA was subsequently terminated and returned the misappropriated funds to the resident. Interviews with the former administrator, the resident, the resident's responsible party, and other staff members confirmed that the CNA had violated facility policy by accepting and using the resident's debit card. The financial counselor also corroborated the resident's claim by reviewing the credit card statements and reporting the issue to the former administrator. The facility's policy clearly states that staff are not allowed to take money from residents, and this policy was breached in this instance.
Failure to Provide Required Two-Person Assistance Results in Resident Fall
Penalty
Summary
The facility failed to provide the required two-person assistance to a resident (R5) who needed such assistance, resulting in the resident falling during a shower. R5's medical record indicated multiple diagnoses, including multiple sclerosis, functional quadriplegia, and muscle weakness, and the resident was assessed as totally dependent on two or more persons for physical assistance. Despite this, during a shower, only one CNA was present, and R5 fell while being dressed after the shower. The facility's policy on fall occurrence reduction was not followed, as the resident was not provided with the necessary two-person assistance, leading to the fall. Interviews with the resident and staff confirmed the incident. R5 reported falling twice, once due to a Hoyer lift malfunction and the second time during the shower when only one CNA was present. The CNA involved admitted to asking the assisting CNA to leave and attempted to dress R5 alone, resulting in the fall. The post-fall observation noted that the lack of two-person assistance was a contributing factor to the fall. The facility's failure to adhere to its policy and provide adequate supervision and assistance directly led to the incident.
Failure to Lock Medication and Treatment Carts
Penalty
Summary
The facility failed to ensure that medication and treatment storage carts were locked when unattended and out of the view of a nurse. This deficiency was observed in two of six medication carts and one treatment cart. On multiple occasions, medication carts were found unlocked and unattended in the hallways. Specifically, an LPN was observed approaching an unlocked medication cart without the keys, and another nurse admitted to leaving her cart unlocked while attending to a resident in a closed room. Additionally, during a wound care procedure, a treatment cart was left open with the keys in the lock, and another staff member accessed the cart without locking it afterward. Interviews with the Director of Health Nursing and the Administrator confirmed that medication carts should be locked when unattended. The facility's policies on medication storage and administration were reviewed, revealing that only authorized personnel should have access to medications and that carts should be locked or attended at all times. Despite these policies, the observed practices placed residents, staff, and visitors at risk of unauthorized access to medications and potentially hazardous treatment supplies.
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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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