Rosewood At Tybee Island Of Journey Llc, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Tybee Island, Georgia.
- Location
- 7 Rosewood Avenue, Tybee Island, Georgia 31328
- CMS Provider Number
- 115730
- Inspections on file
- 22
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 10 (5 serious)
Citation history
Health deficiencies cited at Rosewood At Tybee Island Of Journey Llc, The during CMS and state inspections, most recent first.
A resident with multiple serious conditions, moderate cognitive impairment, and total dependence for ADLs was placed in bed with side rails intended to assist with positioning, despite the MDS indicating no bed rail use. Facility records showed no evidence of safe rail spacing or regular inspection of the bed and rails. The assigned CNA, who came on duty late in the evening, last saw the resident around the start of the shift and did not check on him again for several hours, relying on the resident to use a call light. In the early morning, the CNA and an RN found the resident partially out of bed, entrapped in the half side rail, requiring multiple staff to free and reposition him. The resident was unresponsive except for moaning, with altered mental status and respiratory failure documented by EMS and the ER, and later expired at the hospital. The facility’s failure to provide required monitoring and to ensure safe side rail use resulted in neglect and Immediate Jeopardy.
The facility did not ensure licensed nurse coverage on one wing during an evening shift, resulting in no nurse on that wing after about 6:00 PM. Two nurses from the day shift reported that no relief nurse arrived, notified the scheduler, DON, and Administrator, stayed several extra hours, then secured the medication cart keys and left. The scheduler confirmed that no licensed nurses were assigned for that shift and that the DON did not come in. Several cognitively intact residents reported that no nurse was available to administer medications, including a diabetic resident who stated he did not receive his medicine until the next day, and a grievance documented that some residents did not receive their scheduled evening doses.
The facility did not ensure that residents were protected from all forms of abuse and neglect, resulting in a deficiency related to the failure to safeguard residents from harm by others.
The facility did not provide adequate nursing staff to meet all residents' needs and failed to have a licensed nurse in charge on every shift, as observed and documented by surveyors.
The facility did not manage its operations to ensure effective and efficient use of resources, as observed by surveyors during their review.
The facility did not set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action, resulting in a lack of systematic review and response to quality issues.
Certified Medication Aides (CMAs) administered medications, including narcotics, without documented annual competency check-offs, and were not certified to give controlled substances. Multiple staff, including RNs and consultants, were unaware that CMAs were administering narcotics, despite facility policy prohibiting this practice. This resulted in unqualified staff administering medications to residents.
A deficiency was identified when clean clothes and linens were found uncovered and coated with dust and debris in the laundry area, with a fan blowing contaminated air onto them. The ceiling, pipes, and equipment were not being cleaned as required, PPE was inadequate and dirty, and there was no proper biohazard container. Staff interviews revealed a lack of awareness and documentation regarding proper laundry sanitation practices.
A resident was taken outside by two CNAs while wearing a hospital gown that was pulled up, leaving the resident's lower body exposed to public view, including construction workers and passing cars. Both CNAs acknowledged they failed to ensure the resident was properly covered, and the DON confirmed this was a dignity issue per facility policy.
A resident with severe cognitive impairment, muscle weakness, and a high fall risk was not provided with fall mats despite a history of falls and repeated attempts to get out of bed or a chair. Staff interviews confirmed that fall mats were not used, and the DON was unaware of their absence, resulting in inadequate supervision and safety measures.
The facility failed to implement pharmacy procedures for the reconciliation of controlled drugs on three medication carts. The policy required documentation and verification of controlled substances by licensed nurses at shift changes. However, reviews of narcotic logs revealed that nurses failed to sign the sheets on multiple dates, indicating a lack of verification. Interviews confirmed the expectation for nurses to sign the logs, and the Nursing Home Administrator acknowledged the deficiency.
A facility failed to create a comprehensive baseline care plan for a newly admitted resident with multiple health conditions. The care plan only addressed nutritional status, neglecting critical needs such as oxygen use, codeine allergy, cognitive deficits, diabetes management, DNR status, and eyeglasses. Staff interviews confirmed the oversight, leading to a deficiency in addressing the resident's immediate needs.
The facility failed to date multi-dose diabetes medications on a medication cart, affecting three residents. During an observation, it was found that three vials of insulin were opened and available for use without being dated, contrary to the facility's policy. An LPN confirmed the oversight, and the Nursing Home Administrator acknowledged the failure to ensure acceptable storage times.
The facility did not adhere to its policy of posting daily nurse staffing information at the beginning of each shift. During a survey, staff could not provide the required postings for certain dates, and a RN admitted to being overwhelmed and unable to organize the files. The Administrator acknowledged the inconsistency in posting the staffing data.
A resident with moderate cognitive impairment was repeatedly observed wearing a hospital gown despite preferring his own clothes, which went missing after a hospital stay. Staff were uncertain about the reason for the gown, and the DON did not see it as an issue, while the Administrator acknowledged the resident's preference for personal attire.
The facility failed to ensure call lights were within reach for four residents, placing them at risk of unmet needs. Observations showed call lights on the floor or out of reach, despite residents having no upper extremity impairments and being dependent on staff for ADLs. Staff interviews confirmed the deficiency, with a CNA and the Administrator acknowledging the issue.
A resident with COPD and CHF did not have a comprehensive care plan addressing their significant health needs, such as ADLs, hospice care, and an indwelling urinary catheter. The facility's policy requires a comprehensive care plan within seven days post-MDS assessment, but the plan only included the resident's enjoyment of activities, omitting critical health areas.
The facility failed to provide adequate assistance with activities of daily living (ADLs) for four residents, leading to unmet needs and diminished quality of life. Residents with cognitive impairments and physical limitations were observed with long, dirty fingernails, and one resident was left in a soiled state for several hours. Staff interviews revealed a lack of awareness and prioritization of residents' needs, contributing to the deficiencies in care.
A resident with HIV experienced a five-day delay in obtaining a urine specimen for a urinalysis, culture, and sensitivity test, despite a physician's order. The resident suffered severe pain during this period. Staff interviews revealed confusion and lack of responsibility in collecting the specimen, with the DON and physician acknowledging the delay as unacceptable.
Two residents in a facility shared a single water mug, contrary to infection control policies. One resident, with moderate cognitive impairment, reported not being offered his own mug, while the other confirmed sharing since admission. The DON was unaware of this issue until it was highlighted, and the shared mug was found to be filthy, indicating a lapse in infection control measures.
Neglect Related to Inadequate Supervision and Unsafe Side Rail Use Leading to Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect related to inadequate supervision and oversight of side rail use, resulting in entrapment. Facility policies on Abuse, Neglect and Exploitation required protections to prevent neglect, defined as failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. The policy on Proper Use of Bed Rails required a person-centered approach, attempts at alternatives before bed rail use, and ensuring correct installation, use, and maintenance of bed rails, including attention to entrapment risk. For this resident, the Medicare 5-day MDS indicated moderate cognitive impairment (BIMS score of 8), total dependence on staff for all ADLs, and documented that bed rails were not used, while an admission assessment documented side rails were placed to assist with movement in bed. Facility records showed no evidence that safe rail spacing and regular inspection of side rails and beds had been completed. The resident had multiple serious medical diagnoses, including acute and subacute infective endocarditis, end stage renal disease, hemiplegia and hemiparesis following cerebral infarction, bacteremia, and cervical disc degeneration, and was dependent on staff for all ADLs. Nursing staff last observed the resident at 12:46 am when a sponge bath was provided; there was no documented monitoring or ADL assistance between 12:46 am and 4:30 am. The assigned CNA reported coming on duty at 11:00 pm, seeing the resident up with the bed in a low position, placing the call light in the resident’s hands, and not seeing or checking the resident again until approximately 4:30–5:00 am, stating that the resident did not press the call light during that time. Around 5:00 am, the CNA requested help from the RN, reporting that the resident needed assistance. The RN found the resident with the lower part of his body hanging off the bed and the upper body still on the bed, with his elbow wedged into the half side rail, requiring three staff to reposition him back into bed. The RN stated the resident, who was quadriplegic, was no longer as alert as when put to bed, did not respond to sternal rubs, had open but unfocused eyes, and was not verbally interactive. The CNA described finding the resident on his knees, all the way out of bed, with one hand tangled in the side rail, and noted that he was moaning but not talking after being returned to bed. Progress notes documented that EMS was called for evaluation and treatment due to the resident’s condition, and hospital ER records indicated he arrived with altered mental status and respiratory failure, agonal respirations, and a GCS of 3. The facility’s Maintenance Director stated bedrails had been checked the prior year but could not provide proof, and requested documentation of safe rail spacing and regular inspection was not provided.
Lack of Licensed Nurse Coverage on One Wing Leading to Missed Medications
Penalty
Summary
The facility failed to provide sufficient licensed nursing staff on the [NAME] Wing during the 3:00 PM to 11:00 PM shift on December 25, 2025, resulting in no licensed nurse coverage after approximately 6:00 PM. The facility’s daily staffing document for that date showed no licensed nurse scheduled for the [NAME] Wing on the 3:00 PM to 11:00 PM shift. The scheduler confirmed that no licensed nurses were assigned for that shift on the [NAME] Wing and that she was unable to fill the assignments despite using agency staff and being aware of multiple call-outs. She stated that the DON was notified and did not come in to work the shift, and the Administrator later reported being unaware that there was no nurse on the wing after 6:00 PM. On December 25, 2025, two nurses (an LPN and an RN) worked the [NAME] Wing day shift and reported that no nurse arrived to relieve them at 3:00 PM. Both nurses stated they notified the scheduler, DON, and Administrator that there was no relief nurse. One nurse reported that the DON told her there was nothing she could do. Both nurses remained on duty until nearly 6:00 PM, then counted the medication cart together, secured the medication keys in the locked medication room or at the nurse’s station, and left the facility, leaving the [NAME] Wing without licensed nurse coverage for the remainder of the evening shift. A regional nurse consultant later confirmed there was no nurse on the [NAME] Wing after 6:00 PM on that date. Multiple residents with little to no cognitive impairment, as evidenced by BIMS scores of 14 and 15 on their quarterly MDS assessments, reported that there was no nurse available on the [NAME] Wing during the evening of December 25, 2025. One resident stated that there was no nurse after 3:00 PM to give medications, and another resident reported that there had been a couple of days, usually around holidays, when no nurse was available. A resident who returned from an outing with family around 7:00 PM stated there was no nurse working on the [NAME] Wing and that, as a diabetic, he did not receive any medicine until the next day. A grievance/complaint report filed by the DON on December 26, 2025, documented that some residents on the [NAME] Wing reported not receiving their 9:00 PM medications on December 25, 2025, and that the Medical Director was notified.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by anybody. This deficiency indicates that residents were not adequately safeguarded from potential or actual harm caused by others, as required by regulations. The report identifies a lapse in the facility's responsibility to ensure a safe environment free from abuse and neglect for all residents.
Insufficient Nursing Staff and Lack of Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified through observations and review of staffing patterns, which showed that staffing levels were insufficient to meet resident care needs and that there were shifts without a licensed nurse in charge. These findings indicate that the facility did not comply with requirements for daily nursing staff coverage and supervision by a licensed nurse on every shift, as observed and documented by surveyors.
Failure to Administer Facility Resources Effectively
Penalty
Summary
The facility failed to administer its operations in a manner that enabled effective and efficient use of its resources. This deficiency was identified based on observations and findings documented by surveyors, indicating that the facility's management practices did not support optimal resource utilization. Specific actions or inactions leading to this deficiency were not detailed in the report.
Failure to Establish Ongoing Quality Assessment and Assurance Group
Penalty
Summary
The facility failed to establish an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. This inaction resulted in the absence of a systematic process for identifying, reviewing, and addressing quality issues within the facility. As a result, there was no documented evidence that quality deficiencies were being regularly reviewed or that corrective plans were being developed and implemented to address identified issues.
CMAs Administered Medications Without Required Competency and Gave Narcotics
Penalty
Summary
Certified Medication Aides (CMAs) at the facility were permitted to administer medications, including narcotics, without having completed the required skills competency check-offs. Review of facility records showed that six out of seven active CMAs did not have current, signed, and dated annual competency documentation. Additionally, one CMA's skills checklist specifically indicated that she was not certified to administer narcotic medications, yet records showed that she had administered a narcotic medication to a resident. Staff interviews confirmed that CMAs were administering narcotics, and some staff members, including a Registered Nurse, admitted to giving narcotics to CMAs to administer to residents. Multiple facility staff, including the Regional Consultant Nurse, Interim Director of Nursing, Operations Consultant, Medical Director, and Nurse Practitioner, were unaware that CMAs were administering narcotics or controlled substances. The facility's own policy and staff statements indicated that CMAs were not supposed to administer narcotics, yet this practice was occurring. The lack of proper competency verification and unauthorized administration of narcotics by CMAs placed all residents at risk of receiving medication from unqualified personnel.
Failure to Maintain Sanitary Laundry Conditions Resulting in Cross-Contamination Risk
Penalty
Summary
The facility failed to maintain the laundry area in a sanitary manner, resulting in the potential for cross-contamination of residents' clothing and linens. Observations revealed a thick, dark greyish substance coating the ceiling, pipes, and a large industrial fan in the laundry room. Clean clothes, blankets, sheets, and pillowcases were found uncovered and coated with dust and debris. The fan, also covered in dust, was blowing directly onto clean laundry. Additionally, a window in the laundry room was covered with dust and broken glass, further exposing clean laundry to contamination. There was only one apron available as PPE, which was itself coated with dust and debris, and no other PPE was present. No separate designated hazardous container was available; instead, a trash can was being used for biohazardous materials. Interviews with staff revealed a lack of awareness regarding the need to cover clean laundry and the proper use of PPE. The Housekeeping Manager and Laundry Aide both confirmed that cleaning of the ceiling and pipes was not being performed as required, and the Laundry Aide reported never seeing these areas cleaned. The Director of Nursing/Infection Preventionist stated she was unaware of the laundry room's condition. Requested cleaning logs for the laundry room were not provided, indicating a lack of documentation and oversight in maintaining sanitation standards in the laundry area.
Resident Exposed While Outside, Dignity Not Maintained
Penalty
Summary
Certified Nursing Assistants (CNA) II and CNA JJ were observed pushing a resident in a geriatric chair outside of the facility. The resident was wearing a hospital gown that was pulled up above his stomach, with a blanket folded across his chest, leaving his legs and lower torso exposed. This exposure revealed the resident's brief and bandages on his right leg stump. The observation took place in an area visible to construction workers and passing cars on a nearby street. During concurrent interviews at the time of the observation, both CNAs confirmed that they did not ensure the resident's body was properly covered and acknowledged that they should have done so. The Director of Nursing (DON) later confirmed that staff are expected to ensure residents are properly dressed and not exposed, and agreed that this incident constituted a dignity issue. The facility's policy on promoting and maintaining resident dignity requires all staff to provide care in a manner that maintains or enhances each resident's quality of life and respects their rights.
Failure to Provide Fall Prevention Measures for High-Risk Resident
Penalty
Summary
A deficiency was identified when the facility failed to implement appropriate safety measures for a resident with multiple risk factors for falls, including muscle weakness, epilepsy, unsteadiness on feet, and severe cognitive impairment. The resident was assessed as a high fall risk, with a history of falls documented in progress notes, including incidents where the resident was found on the floor or observed attempting to get out of bed or a chair. Despite these risk factors and repeated fall incidents, observations revealed that no fall mats were placed around the resident's bed or chair during multiple checks, and the bed was only placed in the lowest position. Interviews with staff confirmed that the resident was capable of moving in bed and often attempted to get out of bed or the geriatric chair. Staff reported they were not instructed to use fall mats, and the DON was unaware that fall mats were not in place, despite knowing the resident was a high fall risk. These actions and inactions resulted in the facility failing to ensure adequate supervision and safety measures to prevent accidents for this resident.
Failure to Reconcile Controlled Drugs
Penalty
Summary
The facility failed to implement proper pharmacy procedures for the reconciliation of controlled drugs across three medication carts. The facility's policy required that all controlled substances obtained from a non-automated medication cart or cabinet be recorded on a designated usage form, with a daily visual audit conducted by the charge nurse or designee. Additionally, two licensed nurses were expected to account for all controlled substances and access keys at the end of each shift. However, the review of the Change of Shift Narcotic Logs for the West Medication Cart One, [NAME] Medication Cart Two, and East Medication Cart revealed that the on-coming and/or off-going nurses failed to sign the sheets during shift changes on multiple dates, indicating a lack of verification for the completion of the controlled drug count. Interviews with LPNs AA, BB, and CC confirmed the observations and acknowledged that licensed nurses were expected to sign the count verification at the change of shift. The Nursing Home Administrator also confirmed the lack of additional documentation and stated that it was her expectation for nursing staff to sign the Control Substance logs at shift changes to identify any discrepancies. The failure to adhere to these procedures resulted in the facility's inability to properly reconcile controlled drugs, as required by their policy.
Failure to Develop Comprehensive Baseline Care Plan
Penalty
Summary
The facility failed to develop a comprehensive baseline care plan for a resident within 48 hours of admission, as required. The resident, who was admitted with multiple diagnoses including acute respiratory failure with hypoxia, dysphagia, cognitive communication deficit, essential hypertension, type 2 diabetes mellitus, restless legs syndrome, and insomnia, had a baseline care plan that only addressed nutritional status. Critical care needs such as the use of oxygen, an allergy to codeine, cognitive communication deficits, diabetes management, DNR code status, and the use of eyeglasses were not documented or addressed in the baseline care plan. Interviews with facility staff, including an LPN/MDS Coordinator and the Nursing Home Administrator, confirmed the oversight. The LPN acknowledged the single entry in the care plan and the failure to include essential healthcare information. The Nursing Home Administrator also confirmed that the facility did not adequately address the resident's care and management needs in the baseline care plan, leading to a deficiency in meeting the resident's immediate needs upon admission.
Failure to Date Multi-Dose Diabetes Medications
Penalty
Summary
The facility failed to adhere to acceptable storage requirements and use-by dates for multi-dose diabetes medications on one of the medication carts, specifically West Cart Two. During an observation, it was found that three vials of insulin, belonging to three different residents, were opened and available for use without being dated when initially opened. This is contrary to the facility's policy, which requires multi-dose vials to be re-labeled with a beyond-use date 28 days after being opened, unless otherwise specified by the manufacturer. The policy also mandates that the medication label should include the initials of the nurse who opened the vial, and that staff should visually inspect the vial before each use to check the expiration date and ensure there is no visible contamination. The observation was confirmed by an LPN present at the time, who acknowledged that the medications should have been dated when opened. Additionally, the Nursing Home Administrator confirmed that the facility failed to date multi-dose medications when opened, which is necessary to assure acceptable storage times. This deficiency affected three residents who were using the diabetes medications stored on the cart.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post daily nursing staffing data, as observed during a four-day survey. The facility's policy mandates that the Nurse Staffing Sheet be posted at the beginning of each shift daily. However, upon request, the staff was unable to provide the postings for certain dates. During an interview, a Registered Nurse admitted to being unable to locate the nurse staffing data, citing an overwhelming workload and difficulty in organizing files. The Administrator later acknowledged the inconsistency in posting the Daily Nurse Staffing information.
Resident Dignity Compromised by Inappropriate Attire
Penalty
Summary
The facility failed to ensure that a resident, identified as R2, was treated with dignity, which potentially diminished his quality of life. R2, who has moderate cognitive impairment as indicated by a BIMS score of 10, was observed multiple times wearing a hospital gown despite having brought his own clothes to the facility. R2 expressed a preference for wearing his own clothes and mentioned that his clothing went missing after a hospital stay, although he could not recall if this was reported. Staff interviews revealed uncertainty about why R2 was consistently in a hospital gown, with one CNA stating she would change his clothes and another mentioning that R2 is dressed in sweatpants and a shirt for dialysis. The Director of Nursing stated that residents who do not get out of bed typically wear hospital gowns and did not identify this as an issue for R2. However, the Administrator confirmed that R2 was particular about his appearance and should not be in a hospital gown unless he desired it. This lack of attention to R2's preferences and the failure to address the missing clothing contributed to the deficiency in maintaining the resident's dignity and quality of life.
Call Lights Not Within Reach for Residents
Penalty
Summary
The facility failed to ensure that the call lights were within reach for four residents, which placed them at risk of accident, injury, and/or unmet needs due to their inability to call for staff assistance. Observations revealed that the call lights for these residents were either on the floor, coiled around bed rails, or positioned over the headboard, making them inaccessible. Each of these residents was documented as having no impairment of the upper extremities and was dependent on staff for activities of daily living (ADLs). Interviews with staff confirmed the deficiency, with a Certified Nursing Assistant (CNA) acknowledging that the call lights were not within reach and should not be on the floor. The facility's Administrator also stated that call lights should always be within the residents' reach. These observations and interviews highlight a failure in the facility's responsibility to reasonably accommodate the needs and preferences of each resident, as required.
Deficient Care Planning for Resident
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan for a resident, identified as R4, which is a deficiency in their care planning process. The facility's policy on Comprehensive Care Plans requires that a comprehensive care plan be developed within seven days after the completion of the comprehensive Minimum Data Set (MDS) assessment. This care plan should consider all Care Assessment Areas triggered by the MDS and describe the services necessary to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. However, the review of R4's care plan, dated August 14, 2023, revealed that it only included a focus area on the resident's enjoyment of activities such as TV, music, and arts and crafts, without addressing critical areas such as activities of daily living (ADLs), chronic obstructive pulmonary disease (COPD), hospice care, or the management of an indwelling urinary catheter. R4 was admitted with diagnoses including chronic obstructive pulmonary edema (COPD) and congestive heart failure (CHF), and the MDS indicated that R4 required assistance with ADLs, had an indwelling urinary catheter, and was receiving hospice services. Despite these significant health needs, the care plan did not include focus areas for these conditions, which are essential for providing appropriate care. An interview with the Director of Nursing (DON) confirmed that baseline care plans are created upon admission, and a comprehensive person-centered care plan should be developed by the 14th day. The DON acknowledged that the care plan is used by nurses to determine the type of care a resident requires, highlighting the importance of having a comprehensive plan in place for R4's care needs.
Failure to Provide Adequate ADL Care for Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for four residents, leading to unmet needs and diminished quality of life. Resident 18, with cognitive communication deficit and muscle weakness, was observed with long, dirty fingernails and reported that staff rarely offered to trim them. Resident 20, diagnosed with hemiplegia and muscle weakness, also had untrimmed, dirty nails and stated that staff were too busy to assist. Resident 16, with severe cognitive impairment and muscle weakness, had not had his nails trimmed in six months, as confirmed by staff interviews. Certified Nursing Assistant (CNA) HH admitted to not having time to trim residents' nails, and Licensed Practical Nurse (LPN) CC was unaware of the need for nail care. Resident 15, with severe cognitive impairment and incontinence, was found lying in bed with a strong odor of bowel movement, indicating a lack of timely incontinent care. Despite being aware of the situation, CNA FF prioritized passing out meal trays over providing immediate care to Resident 15. The Director of Nursing (DON) and the Administrator acknowledged that staff should have checked on Resident 15 every two hours and provided necessary care promptly. The failure to provide timely ADL care for these residents highlights significant deficiencies in the facility's care practices.
Delayed Urine Specimen Collection for Resident
Penalty
Summary
The facility failed to obtain a critical laboratory test for a resident in a timely manner, specifically a urine specimen, which was delayed for five days after the physician's order. The resident, who has a diagnosis of Human Immunodeficiency Virus (HIV) and a BIMS score indicating little to no cognitive impairment, experienced urinary discomfort and severe pain. Despite the physician's order for a urinalysis, culture, and sensitivity test on 8/8/2024, the specimen was not collected until 8/13/2024. The delay in obtaining the urine sample was noted in the resident's progress notes, and the resident reported relief and decreased pain once the sample was finally collected. Interviews with staff revealed a lack of clarity and responsibility in collecting the urine specimen. An LPN acknowledged the order but did not attempt to collect the sample, passing the information to another nurse whose identity was not recalled. Another LPN confirmed the procedure for collecting a specimen but was unsure why it was delayed. The Director of Nursing verified the order and stated it should have been collected promptly, expressing unawareness of the delay. The physician emphasized that such orders should be executed within 12 to 24 hours, deeming the five-day delay unacceptable.
Failure to Provide Individual Water Mugs for Residents
Penalty
Summary
The facility failed to implement proper infection control precautions by not providing individual water mugs for two residents, R19 and R33, who shared a single water mug in their room. This oversight was identified through observations, resident interviews, and staff interviews. R19, who had moderate cognitive impairment and required minimal assistance with ADLs, reported that staff did not offer him his own water mug, leading to him and R33 sharing the same mug. R33, who had little to no cognitive impairment and also required minimal assistance with ADLs, confirmed that he had been sharing the water mug with R19 since his admission. The facility's policy on infection control, dated 4/1/2024, mandates the establishment and maintenance of an infection prevention and control program to prevent the transmission of communicable diseases. However, the Director of Nursing (DON) was unaware of the shared water mug situation until it was brought to her attention. Upon inspection, the DON found the shared mug to be filthy and acknowledged the infection control concern. The Administrator also confirmed that residents should not share water mugs, indicating a lapse in adherence to the facility's infection control policy.
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Surveyors found that clean linens and personal clothing were stored and staged in close proximity to the dirty laundry area, with an open door between the clean and soiled sides and all washer and dryer doors open. Clean resident clothes, unlabeled garments, and bagged items were placed next to dryers and directly in front of the dirty linen room, and dirty barrels had to be pushed past racks of clean clothing to reach the washers, contrary to facility policies requiring separation of clean and soiled linens. Environmental staff believed keeping doors open and covering dirty barrels reduced infection spread, while the Environmental Services Director, IP nurse, and Administrator acknowledged that the dirty room door should be closed, linens should not be on dirty barrels, and clean resident clothing should not be stored in that location.
A resident with a suprapubic catheter, colostomy, sacral wound, and dependence on staff for bathing and hygiene was care planned for Enhanced Barrier Precautions (EBP), including use of PPE during high-contact care. During observed catheter care and a bed bath, a CNA wore only gloves and did not don a gown, despite EBP signage and a star posted on the door and PPE supplies available outside the room. In interviews, the CNA admitted forgetting to wear a gown and not recognizing additional required actions, while the IP nurse and DON confirmed that staff had been educated that gowns and gloves are required for high-contact care involving indwelling devices and wounds under the facility’s EBP policy.
A resident with multiple neurologic and psychiatric diagnoses, intact cognition, and unilateral functional limitations was found with an open box of lubricant eye drops stored at the bedside without any documented assessment for self-administration or prescriber’s order for self-administration or bedside storage, contrary to facility policy. Observations on multiple days confirmed the eye drops remained at the bedside, while staff interviews showed that CNAs and the IP recognized that residents were generally not to self-administer medications and that bedside medications required assessment and orders. The Administrator confirmed that the resident should not have had eye drops in the room and that residents with bedside medications are typically assessed for self-administration, and staff acknowledged that unsecured eye drops at the bedside could be accessed or ingested by other residents and cause harm.
The facility failed to maintain a safe, clean environment when multiple ceiling tiles throughout the building, including above a resident’s bed, near the nurses’ station, in a glass day room above a resident’s chair, and in a main hall, were observed with brown circular stains, bulging, and a white moldy substance. The Maintenance Director confirmed the stained and bulging tiles, acknowledged the risk that tiles above a resident’s bed could fall, and attributed the condition to rain-related roof leaks. The Administrator also confirmed that roof leaks and recent rainfall caused the brownish stains despite her reported daily rounds.
A resident with severe cognitive impairment, on hospice and fully dependent for ADLs, was sexually abused when another cognitively impaired male resident with a long-standing history of sexually inappropriate behavior toward female residents entered her room and placed his hand inside her pants. The abusing resident had multiple dementia and psychiatric diagnoses, was care planned for sexually inappropriate behaviors with prior documented incidents, and was on psychotropic medication for OCD-related sexual obsession. Despite these known risks and existing care plan interventions, he was able to access the female resident’s room and make inappropriate physical contact, and the facility’s investigation substantiated the abuse.
Surveyors found that the facility failed to develop and implement complete, person-centered care plans for two residents. One resident was receiving an antipsychotic (Haloperidol) for schizophrenia with associated behavior and side-effect monitoring orders, but there was no corresponding care plan addressing antipsychotic use or its indication. Another resident had an indwelling Foley catheter for neurogenic bladder related to prostate cancer, with goals to prevent catheter-related trauma; however, the care plan omitted key interventions such as balloon volume parameters and use of a leg strap or securement device, despite physician orders requiring a leg strap and observations showing the catheter positioned under the leg without securement. An MDS coordinator and the administrator acknowledged that required interventions and standard catheter care components were missing from the care plans.
A resident with a history of resistiveness to care and noncompliance with the non‑smoking policy had a comprehensive care plan that was not updated to reflect multiple interventions implemented in response to repeated smoking and vaping violations. Although the care plan noted the need for supervision while smoking and review of the smoking policy, it did not include measures such as daily room searches for smoking materials, added smoke detection in the room, relocation closer to the nurses’ station, q2h visual rounds for smoke, post‑outing nursing checks, initiation of a PAR process for vaping, or issuance of a discharge notice. Facility forms showed inconsistent documentation of daily room searches and incomplete IDT documentation on the PAR tracking, despite multiple documented episodes of policy violations and removal of vaping devices.
A cognitively intact but physically impaired resident with a history of noncompliance with the facility’s non‑smoking policy repeatedly smoked and vaped in his room while keeping multiple vape devices and other items at bedside. The facility’s Smoking Policy required that non‑compliant smokers have daily documented searches and be prohibited from keeping smoking materials in their rooms, yet monitoring forms showed many days without documented searches, Patient at Risk tracking was incomplete, and staff acknowledged that daily room checks and frequent rounds were not consistently performed. Multiple staff, including a CNA, social worker, Infection Preventionist, MDS coordinator, Activities Director, and the Administrator, reported ongoing violations and repeated discovery of vape devices in the resident’s room, including during surveyor observations, demonstrating that the environment was not maintained free from accident hazards and that required supervision and monitoring were not reliably implemented.
Surveyors found that a treatment cart containing topical medications was left unlocked and unattended in a hall across from a resident’s room after wound care was completed by an LPN. The facility’s policy requires that medication carts and supplies be locked or attended and accessible only to licensed or otherwise authorized staff. During interviews, the LPN confirmed the cart had been left unlocked and unattended, the IP LPN confirmed the LPN’s report that the cart was left unlocked, and the Administrator stated that all medications, including topical medications, were expected to be locked when not in sight of authorized staff.
The facility failed to implement its infection prevention and control program by not operationalizing a documented Legionella water management plan despite having a written policy, and by not fully implementing Enhanced Barrier Precautions (EBP) for residents with indwelling devices and other risks. A resident with an indwelling urinary catheter had no EBP care plan or orders, no EBP signage, and staff providing catheter care wore only gloves without gowns, while multiple staff members reported not knowing what EBP was or misidentified who should be on EBP. Another resident receiving tube feeding had care initiated by an LPN who wore gloves but no gown and repeatedly touched her hair with the same gloved hands before handling the feeding tube and equipment, later acknowledging she should have changed gloves and was unaware of EBP requirements, even though other clinical staff stated gowns and gloves should be used for feeding tube care. A resident on isolation for C. diff had a door sign indicating isolation but no instructions for visitors on required PPE or to seek staff guidance, and the IP confirmed there was no system to direct visitors about precautions, contributing to the overall infection control deficiency.
Failure to Maintain Separation of Clean and Soiled Laundry
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to separation of clean and soiled linens. Facility policies titled “Infection Prevention and Control Program” and “Handling Soiled Linens” required that clean linen always be separated from soiled linen. During an observation of the laundry area, all washer and dryer doors were open in the clean linen area. Clean linens, including sheets, towels, blankets, and washcloths, were folded on a table to the left of the washer and dryer room. On the right side of the room, next to the dryers and directly in front of the open door to the dirty laundry room, there were residents’ clean clothes on a rack, piles of folded clean clothes to be hung, a rack of unlabeled clothes, and a bag of unlabeled clothes. Dirty laundry barrels had to be pushed past the clean clothing on the racks to reach the washers, placing soiled items in close proximity to clean items despite policy requirements for separation. Environmental staff working in the laundry stated they believed they were reducing the spread of infection by keeping all doors open, covering dirty barrels, and circulating air, and they explained that the uncovered rack and bagged clothes near the dirty area were no-name clothes sometimes distributed to residents in need. They also stated that the rack of clean personal resident clothing parked in front of the open dirty linen room door was awaiting distribution by a staff member who worked only at night. The Environmental Services Director reported that the door to the dirty side of the laundry should always be closed and that no linen should be on top of dirty barrels. The Infection Preventionist nurse, when shown pictures and concerns about cross-contamination, confirmed there was a problem in the laundry but stated she had not been aware of it previously. The Administrator stated that residents’ clothes should not be stored where they were observed and should be handed out immediately once clean, and that she expected the laundry to be organized to prevent cross-contamination between dirty and clean clothes.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff followed its Enhanced Barrier Precautions (EBP) policy for the use of personal protective equipment (PPE) during high-contact care. The facility’s EBP policy, updated February 2025, requires gowns and gloves for residents with wounds and/or indwelling medical devices, including urinary catheters and ostomies, when staff perform high-contact activities such as bathing, dressing, toileting, hygiene, and catheter care. The policy also directs that gowns and gloves be made available near or outside the resident’s room and that EBP be implemented for residents with indwelling devices or wounds, even if they are not known to be infected or colonized with a multidrug-resistant organism. The resident involved had a suprapubic catheter, colostomy, sacral wound, and neurogenic bladder and bowel, and was care planned for EBP implementation during catheter and skin care. The resident was cognitively intact but dependent on staff for bathing, dressing, toileting, hygiene, bed mobility, and transfers, and used an indwelling catheter and ostomy. During an observation, a CNA provided suprapubic catheter care and a bed bath to this resident while only wearing gloves, despite EBP signage and a star posted on the door and PPE supplies available outside the room. The CNA did not don a gown and was unable to identify any additional actions needed before care until prompted about the EBP signage, at which point he acknowledged he should have worn a gown but forgot. In a subsequent interview, the IP nurse and DON confirmed that staff had been educated that gowns are required during high-contact care for residents with catheters, colostomies, and other devices, and that the posted signage and star were intended to alert staff to the need for enhanced PPE use.
Failure to Assess and Obtain Orders for Self-Administration and Bedside Medication Storage
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policies for self-administration of medications and bedside medication storage for one resident. The facility’s policies require that residents who wish to self-administer medications must be assessed by the interdisciplinary team for cognitive, physical, and visual ability, and that a prescriber’s order for self-administration and bedside storage must be present in the medical record and reflected on the MAR and medication label. For the resident in question, who had diagnoses including cerebral infarction, major depressive disorder with psychotic symptoms, PTSD, hemiplegia and hemiparesis, speech and language deficits, and cerebral atherosclerosis, the EHR showed no assessment for self-administration and no physician order for self-administration or bedside storage, despite active ophthalmic medication orders. The resident’s MDS documented intact cognition with a BIMS score of 15, use of corrective lenses, and functional limitations in range of motion on one side of both upper and lower extremities. Surveyor observations on two consecutive days found an open box of lubricant eye drops on the resident’s bedside table. Staff interviews revealed inconsistent understanding and enforcement of the facility’s policies. A CNA stated that residents did not self-administer medications and that only nurses administered them, but also reported that when she previously reported the eye drops, she was told the resident could have them because he was independent. The Infection Preventionist acknowledged the resident had an order for eye drops and believed he obtained them from the VA, and stated he should not have the lubricant eye drops because they were a hazard for other people. The Administrator confirmed that typically a resident with medications at the bedside should be assessed for self-administration and stated the resident should not have eye drops in his room. The report notes that unsecured medications at the bedside had the potential to cause adverse reactions if accessed or ingested by other residents.
Failure to Maintain Safe and Clean Ceiling Surfaces Throughout Facility
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable homelike environment as required by its Maintenance Service policy, which assigns the Maintenance Department responsibility for keeping the building in good repair and free from hazards. Surveyors observed multiple stained and damaged ceiling tiles in several areas of the facility, including near the nurses' station, in a resident bedroom (room [ROOM NUMBER]A), in the glass day room, and in the middle of the east hall. On several occasions, ceiling tiles near the nurses' station were noted to have tannish-brown circular stains of varying sizes, and at one point a white, moldy substance was observed on a ceiling tile in that same area. In room [ROOM NUMBER]A, surveyors observed brown rings roughly 16 inches in diameter on ceiling tiles located directly above a resident’s bed, with the Maintenance Director later confirming that these tiles were stained, bulging, and at risk of falling on the resident. Additional observations in the glass day room identified two stained ceiling tiles above a resident’s chair, each with brown circular stains approximately three inches in diameter. In the east hall, a ceiling tile with a brown circular stain approximately 10 inches in diameter was also documented. The Maintenance Director and the Administrator both acknowledged that the stains and damage were related to roof leaks associated with recent rainfall, and the Administrator confirmed awareness of roof leaks that had previously been repaired and that the brownish stains were due to recent rain.
Failure to Prevent Sexual Abuse of a Cognitively Impaired Resident by Another Resident
Penalty
Summary
The facility failed to protect a dependent, cognitively impaired resident (R113) from sexual abuse by another resident (R12). R113 had severe cognitive impairment with a BIMS score of 5, was on hospice care, and was fully dependent for toileting, bathing, dressing, footwear, and personal hygiene. On the day of the incident, a CNA observed R12 in R113’s room with his right hand inside R113’s pants while she was seated in a geriatric chair. Staff witness statements and nursing progress notes documented that R12 was found in R113’s room with his hand in her pants, and the facility’s investigation substantiated that R12 touched R113 inappropriately. R12 also had severe cognitive impairment with a BIMS score of 4 and multiple psychiatric and dementia-related diagnoses, including vascular dementia with mood disturbance, Alzheimer’s disease, major depressive disorder, obsessive-compulsive personality disorder, unspecified psychosis, and unspecified mood affective disorder. He required extensive physical assistance, used a manual wheelchair, and was fully dependent for toileting, bathing, lower body dressing, and footwear. R12’s care plan, in place since 2017, identified him as having sexually verbally and physically inappropriate behavior, including documented prior incidents in which he inappropriately touched or attempted to touch female residents. His care plan included interventions such as discussing his behavior when reasonable, explaining that it was inappropriate, intervening to protect others, diverting his attention, and removing him from situations as needed, as well as monitoring and recording occurrences of target behaviors such as sexual aggression toward others. Despite this known history of sexually inappropriate behavior toward female residents and the presence of care plan interventions, R12 was able to enter R113’s room and place his hand inside her pants. The Administrator confirmed that the CNA reported finding R12 in R113’s room with his hand in her pants while R113 was in her wheelchair, and that the facility’s investigation substantiated the abuse allegation. The facility’s abuse policy stated that it would not condone resident abuse by anyone, including other residents, and defined sexual abuse to include sexual harassment, sexual coercion, or sexual assault. The occurrence of this incident demonstrated that the facility did not effectively prevent sexual abuse of R113 by another resident, despite R12’s documented behavioral history and existing care plan.
Failure to Develop and Implement Complete Care Plans for Antipsychotic Use and Foley Catheter Management
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for identified resident needs, as required by its Comprehensive Care Plan policy. The policy states that care plans must address all needs identified in the comprehensive assessment, including medical, nursing, mental, and psychosocial needs, and must be developed within seven days after completion of the comprehensive MDS assessment. It also requires that all triggered Care Area Assessments (CAAs) and other factors identified by the IDT or resident preferences be incorporated into the plan of care. For one resident, R44, the clinical record showed physician orders for Haloperidol 10 mg by mouth twice daily for schizophrenia, along with orders for behavior monitoring and psychiatric medication side effect monitoring. Despite these orders, the resident’s care plan dated 03/11/2026 did not include any care plan addressing antipsychotic medication use or its indication. The MDS Coordinator stated that all residents receiving antipsychotic treatment should have a comprehensive care plan in place beginning with the date the medication was originally ordered, and upon review of the record confirmed that such a care plan was not present for this resident at the time of the survey. For another resident, R3, the care plan dated 03/13/2026 identified a problem of an indwelling catheter secondary to neurogenic bladder related to prostate cancer, with goals including remaining free from catheter-related trauma. The listed interventions included positioning the catheter bag and tubing below bladder level, monitoring and documenting intake and output per policy, and monitoring for pain, discomfort, and signs and symptoms of UTI. However, the care plan did not address the amount of water in the catheter balloon, use of a leg strap or securement device, or other securement measures. Physician orders specified checking a leg strap every shift and documented that the resident was admitted with an 18F catheter attached to a bedside drainage bag, but observations showed the Foley catheter positioned under the resident’s leg without a leg strap or securement device on two occasions, and a CNA reported being unaware that a leg strap was required. The MDS Coordinator confirmed that these ordered interventions were missing from the care plan.
Failure to Revise Care Plan for Ongoing Smoking Policy Noncompliance
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive care plan to reflect current interventions implemented in response to ongoing noncompliance with the facility’s non‑smoking policy. The facility’s policy requires that the comprehensive care plan be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment, and that it include measurable objectives, timeframes, and alternative interventions as needed, with qualified staff notified when changes are made. The resident’s care plan included a focus on resistiveness to care and noncompliance with smoking, noting that the resident continued to go outside beyond facility property to smoke, and an intervention to review the smoking policy with the resident. Another care plan focus identified the resident as a smoker requiring supervision while smoking, with interventions stating the resident required supervision while smoking and that the charge nurse should be notified if a smoking policy violation was suspected. Despite repeated and ongoing noncompliance with the non‑smoking policy, the care plan was not revised to include additional interventions that were actually implemented. These unreflected interventions included daily room searches for smoking paraphernalia, placement of a smoke detector in the resident’s room, relocation of the resident’s room closer to the nursing station, every‑two‑hour visual rounds to check for smoke, nursing checks upon return from outings, initiation of a Patient at Risk (PAR) process for vaping noncompliance, and issuance of a 30‑day discharge notice for repeated violations of the non‑smoking policy. Documentation on the Smoking Materials Monitoring Form showed initials on selected days only, indicating daily room searches were not consistently completed and documented for the entire month. The PAR Smoking Tracking form documented multiple observations of vaping in the room, repeated room checks, removal of vapor devices, and the resident’s refusal to comply with facility policies, with later weeks lacking IDT signatures and documentation, while the PAR Grid showed multiple prior entries for violating the non‑smoking policy.
Failure to Control Smoking and Vaping Hazards for a Noncompliant Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision for a resident with a known history of noncompliance with the facility’s non‑smoking policy. The facility’s Smoking Policy requires that residents not be allowed to keep cigarettes, cigars, pipes, matches, or lighters in their possession or rooms, and that non‑compliant smokers receive daily searches with documentation, while compliant smokers receive weekly searches. The policy also requires incident reports and review in a “Patients at Risk” process whenever smoking materials are found. Despite these written procedures, the resident’s Smoking Materials Monitoring Form for April showed multiple days without documented searches, indicating that required daily room searches were not consistently completed or recorded. The resident at issue was cognitively intact, with a BIMS score of 15, and had significant physical impairments including hemiplegia and hemiparesis on the left side, use of a manual wheelchair, and other neurologic and psychiatric diagnoses such as cerebral aneurysm, cerebral infarction, major depressive disorder with psychotic symptoms, PTSD, and speech and language deficits. The care plan identified the resident as resistive to care and noncompliant with smoking, noting that he continued to go outside beyond facility property to smoke, and also identified him as a smoker requiring supervision while smoking. Progress notes and Patient at Risk documentation showed a pattern of repeated violations of the non‑smoking policy, including multiple instances of vaping and smoking in his room, with staff repeatedly finding vape devices and other smoking paraphernalia in his possession and in his room. Throughout the period reviewed, staff observations and interviews confirmed ongoing noncompliance with the smoking policy and inconsistent implementation of the facility’s own interventions. Staff documented several occasions when the resident was observed vaping or smoking in his room, including in the presence of a state surveyor, and room searches revealed multiple vape devices hidden under the sheets. Staff interviews indicated that daily room checks were not always performed due to competing demands, that logs of every‑two‑hour rounds were not maintained, and that there was confusion or inconsistency regarding whether the resident could keep items such as air freshener at bedside. The social worker, Infection Preventionist, MDS coordinator, Activities Director, CNA, and Administrator all acknowledged that the resident’s room had to be searched for cigarettes and vaping paraphernalia and that prohibited items were repeatedly found, while documentation showed gaps in the required daily searches and incomplete follow‑through on the Patient at Risk tracking process. These actions and inactions resulted in the environment not being kept free from accident hazards as required by the facility’s policy and regulatory standards. The deficiency is further supported by the facility’s own records showing repeated entries on the Patient at Risk grid for violations of the non‑smoking policy over an extended period, as well as narrative notes describing the resident’s statements that he would continue to vape in his room and would simply obtain new devices if they were confiscated. Despite the known pattern of behavior and the facility’s policy requiring close supervision, daily searches, and thorough documentation for non‑compliant smokers, the monitoring forms and staff interviews demonstrate that these measures were not consistently carried out. The presence of multiple vape devices and cans of air freshener at the bedside during surveyor observations, along with staff acknowledgment that room checks were missed and that logs of frequent rounds were not kept, illustrate the facility’s failure to effectively implement its own safety procedures to prevent accident hazards related to smoking and vaping in the resident’s room.
Unlocked and Unattended Treatment Cart with Topical Medications
Penalty
Summary
Surveyors identified a deficiency related to medication storage when a treatment cart containing topical medications was left unlocked and unattended in a hall. The facility’s policy titled “Medication Storage in the Facility,” effective 10/01/2025, states that the medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff lawfully authorized to administer medications, and that medication rooms, carts, and supplies are to be locked or attended by authorized personnel. During an observation on 04/29/2026 at 9:35 AM, after wound care was provided to resident R3 by the wound care LPN, the treatment cart was observed left in the [NAME] hall across from R3’s room, unlocked and unattended for 30 minutes. In an interview, the wound care LPN confirmed that the treatment cart had been left unlocked and unattended. The Infection Preventionist LPN later confirmed that the wound care nurse told her the cart was left unlocked, and the Administrator stated that her expectation was that all medications, including topical medications, be locked when not in sight of a licensed nurse or authorized person. This deficient practice occurred in a facility with a census of 94 residents and involved the failure to follow the facility’s own policy requiring that medication carts be locked or attended by authorized personnel, resulting in unsecured access to topical medications on the treatment cart.
Failure to Implement Legionella Water Management and Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to provide and implement an infection prevention and control program, including a documented water management plan for Legionella and other waterborne pathogens, and a fully implemented Enhanced Barrier Precautions (EBP) program. The Administrator stated there was no Legionella water program in place, and the Maintenance Supervisor reported he was unaware of the requirement for such a program. This was despite the existence of a written Legionella Water Management Program policy, revised in September 2022, which described the need for an interdisciplinary water management team, detailed water system diagrams, identification of risk areas and situations for Legionella growth, control measures, monitoring systems, and annual review. Interviews confirmed that the expectation was that the facility would be conducting this water program, but it was not being done. The facility also failed to implement EBP for residents with indwelling medical devices and other risk factors, as required by its own policy. One resident with Alzheimer’s disease, urinary obstruction, and emphysema had an indwelling urinary catheter documented in the care plan and physician orders, but the care plan did not address EBP related to the catheter, and there was no order for EBP in the record. During catheter-related care, a CNA wore gloves but did not wear a gown, and there was no EBP signage or PPE setup at the room. Multiple staff members, including CNAs and a housekeeper who regularly worked on the resident’s hallway, reported they did not know what EBP was or incorrectly associated EBP only with residents on Transmission-Based Precautions. The DON acknowledged that an attempt to roll out EBP months earlier had not been completed, and that expected signage and PPE caddies for EBP were not fully in place. Additional infection control lapses were observed during tube feeding care and contact isolation. A resident receiving continuous tube feeding had a care plan and physician’s order for enteral nutrition, and an LPN initiated the feeding while wearing gloves but no gown. During the procedure, the LPN repeatedly touched her hair with the same gloved hands and then handled the feeding tube, pump, and syringe used to inject air and check residuals, only removing gloves and using hand sanitizer at the end. The LPN later acknowledged she should have changed gloves after touching her hair and stated she did not know what EBP was or that a gown was required for feeding tube care, while another LPN and the IP stated that EBP with gown and gloves should be used for feeding tube care and that staff should not touch their hair during care without changing gloves and performing hand hygiene. For a resident with a positive urine culture and a subsequent positive C. difficile culture who was on isolation, the door sign indicated isolation but did not provide instructions for visitors on required precautions or direct them to staff for guidance. The IP confirmed there was no system to direct visitors about PPE use for residents on contact isolation and acknowledged that visitors would not know to wear PPE if it was simply present in or on the door of the room. Overall, the survey findings show that the facility did not operationalize its written Legionella water management policy and did not consistently apply its EBP policy for residents with indwelling devices or wounds. Staff interviews and observations demonstrated a lack of knowledge and implementation of EBP, incomplete use of PPE during high-contact care activities such as catheter care and tube feeding, and unclear isolation signage that did not instruct visitors on appropriate precautions. These combined inactions and omissions in policy implementation, staff education, and practice led to the cited infection prevention and control deficiency.
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