Senior Care Center - Brunswick
Inspection history, citations, penalties and survey trends for this long-term care facility in Brunswick, Georgia.
- Location
- 2611 Wildwood Drive, Brunswick, Georgia 31520
- CMS Provider Number
- 115721
- Inspections on file
- 22
- Latest survey
- July 29, 2025
- Citations (last 12 mo.)
- 32
Citation history
Health deficiencies cited at Senior Care Center - Brunswick during CMS and state inspections, most recent first.
Surveyors found that the dumpster area was not maintained in a sanitary condition, with garbage and litter on the ground, unsecured and damaged dumpster lids, and debris including used nitrile gloves and boxes scattered around. The Dietary Kitchen Manager confirmed the unsanitary conditions and was unaware of staff responsibilities regarding dumpster maintenance.
The facility did not ensure that its services met professional standards of quality, as evidenced by practices that did not align with established guidelines for care delivery.
A medication error rate of 5 percent or greater was identified, indicating that the facility did not maintain medication administration accuracy within acceptable limits as observed by surveyors.
Expired medications and biologicals were found on a medication cart and in two medication storage areas, including expired Allergy Relief, aspirin, and COVID-19 antigen rapid tests. Staff interviews revealed inconsistent checks for expired medications, with some LPNs and the central supply manager acknowledging lapses in their responsibilities. The DON and ADON confirmed that all nurses were expected to remove expired medications, but the deficiency occurred due to lack of consistent adherence to these procedures.
Two residents or their representatives did not receive timely refunds of their trust fund balances after discharge or death, as required by facility policy. Account statements and interviews confirmed that credit balances remained unpaid beyond the 30-day period, and the Administrator acknowledged the delay was due to staff not issuing refunds promptly.
A resident reported that his bed linens had not been changed for a month, which was confirmed by his tracking method and multiple observations. CNAs acknowledged that linens were not changed as often as required due to workload, and both the ADON and DON confirmed that the linens had not been changed as needed.
Four residents did not have appropriate care plan interventions developed or implemented for elopement risk, smoking, or dietary needs. Two residents with cognitive impairment and behavioral issues were not provided with timely elopement risk care plans despite documented incidents and high-risk assessments. Another resident, allowed to smoke under supervision, lacked a required smoking assessment and care plan. A resident with a mechanical soft diet order was served inappropriate food, resulting in a choking incident, despite the correct diet being documented in the care plan.
A resident with a history of coronary angioplasty and moderate cognitive impairment did not receive daily wound care as ordered by the physician. Staff changed the resident's right-hand dressing less frequently than prescribed, with one bandage remaining in place for several days. The LPN responsible was unaware of the daily order, and the Wound Care Nurse was on vacation, leading to a lapse in following the physician's instructions.
The facility did not complete required elopement and smoking risk assessments for two residents. One resident with dementia and a history of wandering was able to exit the building on multiple occasions without an elopement assessment or care plan being completed after the first incident. Another resident, identified as a smoker, did not have a smoking risk assessment or care plan in place prior to being observed smoking, despite being 'grandfathered in' for tobacco use. Staff interviews confirmed awareness of both residents' behaviors, but necessary assessments and documentation were not completed in a timely manner.
A resident with hemiplegia and dysphagia was served a hamburger patty instead of the required ground meat mechanical soft diet, leading to a choking incident. The error occurred when the resident received a meal tray intended for their roommate, and staff confirmed the meal did not meet the prescribed dietary needs.
Surveyors observed that personal care items such as bed pans, bath basins, and urinals were not bagged or labeled in several shared bathrooms, contrary to facility policy. Interviews with a CNA, ADON, and DON confirmed that these items should be cleaned, bagged, and labeled to prevent cross-contamination, but this was not consistently done.
Two shared rooms were found without privacy curtains, as required by facility policy to ensure visual privacy during care. Multiple observations confirmed the ongoing absence of curtains, and both a CNA and the DON acknowledged that all shared rooms should have privacy curtains for each bed.
A resident who was dependent on staff for mobility and required two-person assistance was being transferred from a chair to a bed using a Hoyer lift when the lift pad strap broke, causing a fall. Only one CNA was present during the transfer, and the wrong lift pad was used, resulting in the resident sustaining a skin tear and a right arm fracture.
The facility did not maintain adequate nursing staff to meet residents' needs for ADL assistance, as evidenced by multiple residents not receiving scheduled showers and staff reporting frequent short-staffing. Interviews with residents, CNAs, LPNs, and administrative staff confirmed that staffing shortages led to missed care, with some staff working alone and unable to provide required services.
Three residents with significant medical needs did not receive scheduled showers as required, with documentation and interviews confirming missed care. Staff and the DHS attributed the deficiency to ongoing CNA shortages, resulting in residents not being assisted with activities of daily living as scheduled.
The facility failed to protect residents from abuse, resulting in incidents of sexual and physical abuse. A resident was sexually abused by another resident with a history of inappropriate behavior, and a CNA physically and verbally abused another resident. The facility's abuse prevention and reporting protocols were not effectively implemented, leading to an Immediate Jeopardy situation.
The facility failed to thoroughly investigate allegations of potential sexual abuse between two residents, lacking interviews with the victim, staff, or other residents. Documentation was insufficient, with only two sheets of paper, and no evidence of assessments, notifications, or psychiatric evaluations. Staff interviews revealed a lack of awareness and documentation, leading to an Immediate Jeopardy situation.
The facility failed to create care plans for three residents, leading to deficiencies in addressing abuse and elopement. A resident with severe cognitive impairment was sexually abused without a care plan in place. Another resident experienced verbal and physical abuse from a CNA, yet no care plan was developed. Additionally, a resident at moderate risk for elopement was found outside the facility without a care plan addressing safety precautions. The Administrator was unaware of these omissions, highlighting a lack of communication and oversight.
The facility administration failed to oversee an abuse prevention program, leading to a resident being sexually abused by another resident with a known history of aggressive behavior. The administration did not investigate or prevent further abuse, and care plans for affected residents were not developed. Staff interviews revealed a lack of awareness and communication regarding these issues.
An LPN administered her personal melatonin to two residents without a physician's order, resulting in lethargy. The facility's policies on medication administration and abuse prohibition were not followed, as the LPN did not verify the correct medication or have a physician's order. Staff observed the LPN with melatonin on the medication cart and witnessed her administering it to residents, despite the lack of documentation in the residents' eMAR.
The facility failed to prevent cross-contamination of linens and resident equipment, with clean and dirty linen carts placed side by side and a standup lift used without cleaning. Staff were unaware of proper infection control practices despite recent training, and no related policy was provided during the survey.
A resident in the Memory Care Unit was found with unauthorized medication in their room, which belonged to another resident. The facility's policy requires that no residents in this unit self-administer medications, and staff confirmed that no such assessments had been made. The medication was discovered during an observation, and both the LPN and Administrator acknowledged the oversight, emphasizing the need for regular monitoring of residents' rooms for medications.
A facility failed to report an abuse incident involving a CNA and a resident to the State Agency within the required timeframe. The incident, which included physical and verbal abuse, was observed by two CNA students. Although the former DON stated the incident was reported to local law enforcement and the SA the day after it occurred, there is no evidence of notification to the SA until several days later, violating the facility's policy.
The facility failed to develop discharge plans for several residents, despite their participation in discharge planning. Residents with conditions such as cerebral palsy, dementia, and respiratory failure had no documented discharge care plans in their EMRs. Staff interviews revealed confusion about responsibility for completing these plans, with the administrator stating that nursing staff or a social worker should handle them.
A facility failed to provide a complete discharge summary for a resident discharged with a hip fracture and Stage 2 Pressure Ulcer. The discharge summary lacked a medication list and a post-discharge plan of care. Interviews with staff revealed that the RN Supervisor was unaware of the requirements for medication reconciliation and discharge summary completion. The MDS Coordinator confirmed the form was available in the EMR but not completed, and the Administrator stated that the nursing staff or social worker should have completed these tasks.
A resident with cerebral palsy and functional quadriplegia did not receive necessary passive range of motion (PROM) treatment for stiffness in the right hand, despite being referred to occupational therapy. The facility lacked a structured restorative program, and communication failures among staff led to the resident's decline not being addressed in meetings, resulting in a deficiency.
The facility failed to properly store respiratory equipment for two residents, leading to potential risks of respiratory complications. An AutoPap mask and a container of distilled water were not stored or labeled correctly, and nebulizer and Trilogy masks were left on a bedside dresser. Staff interviews revealed a lack of clarity and compliance with storage policies.
A resident was administered PRN Ativan beyond the 14-day limit without a stop date or documented rationale. Facility staff, including the DON and RN Supervisor, were unaware of the regulatory requirements for PRN psychotropic medications. Despite pharmacy recommendations, the necessary documentation and orders were not updated, leading to non-compliance with facility policy and regulations.
Improper Disposal and Maintenance of Dumpster Area
Penalty
Summary
Surveyors observed that the facility failed to maintain the dumpster area in a sanitary condition. During an initial tour, garbage and litter were found on the ground around the dumpsters, and three out of four dumpster lids were not secured and remained open. One dumpster lid was damaged, preventing it from closing properly and allowing trash to be exposed. Additional debris, including used nitrile exam gloves, boxes, and other litter, was found both around and behind the dumpsters. Interviews with the Dietary Kitchen Manager (DKM) confirmed the unsanitary conditions, including the unsecured lids and the presence of debris and litter. The DKM acknowledged that the lids should always be closed and that trash should not be left on the ground or behind the dumpsters. The DKM also stated he was unaware that maintaining the dumpster area was the kitchen staff's responsibility and was not previously aware of the condition of the dumpsters. Subsequent observation revealed no improvement in the dumpster area's condition.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality. This deficiency was identified based on observations and review of facility practices, which did not align with established professional guidelines for care delivery. Specific details regarding the actions or omissions that led to this deficiency, as well as information about the residents involved or their medical conditions, were not provided in the report.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
A medication error rate of 5 percent or greater was identified during the survey. This indicates that the facility failed to ensure that the administration of medications was performed with an acceptable level of accuracy, resulting in a higher than permitted rate of medication errors. The deficiency was based on direct findings by surveyors regarding the facility's medication administration practices.
Expired Medications Found in Multiple Storage Areas
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were discarded prior to their expiration dates, as required by both professional standards and the facility's own policy. During observations, expired medications were found on one of nine medication carts (Harbor Side) and in two of six medication storage areas (Central Supply and Ocean Breeze). Specifically, a bottle of Allergy Relief with an expiration date of January 2025 was found on a medication cart, two bottles of aspirin with a June 2025 expiration date were found in central supply, and two boxes of COVID-19 antigen rapid tests with a use-by date of April 2025 were found in a medication room. Staff interviews revealed that nurses and aides did not consistently check for expired medications, especially when working outside their usual assignments or after returning from days off. Some staff acknowledged that checking for expired medications was their responsibility but admitted to oversights. Further interviews indicated that the central supply manager was responsible for auditing and rotating stock in the supply closet, but was unsure if expired items were returned to her area by nursing staff. The Director of Nursing and Assistant Director of Nursing confirmed that all nurses were expected to dispose of expired medications immediately and that the pharmacy conducted monthly checks. However, the presence of expired medications in multiple locations demonstrated that these procedures were not consistently followed, leading to the deficiency.
Failure to Timely Refund Resident Trust Fund Balances After Discharge or Death
Penalty
Summary
The facility failed to ensure that residents or their representatives received a final refund of trust fund balances within 30 days of discharge or expiration, as required by facility policy. Specifically, two out of three resident accounts reviewed showed that the refunds were not issued in a timely manner. One resident, who had expired, had a credit balance of $25.01 that was not refunded to the representative within the required timeframe. Another resident, who was discharged, had a credit balance of $57.66 that was also not refunded promptly. Interviews with the residents' representatives confirmed that they had not received the funds and had experienced delays and difficulties in obtaining the refunds. The deficiency was further substantiated by interviews with the facility Administrator, who acknowledged that the financial services staff responsible for issuing refunds had been terminated due to failure to return funds to residents or their representatives in a timely manner. The Administrator confirmed the outstanding balances owed to both residents' representatives and indicated that the issue was known to facility leadership. The review of facility policy and resident account statements supported the finding that the required refunds were not processed within the specified 30-day period.
Failure to Provide Clean Bed Linens for Resident
Penalty
Summary
A deficiency was identified in one resident room on the 200 hall where clean bed linens were not provided for an extended period. The resident in the affected room reported that his sheets had not been changed in a month and demonstrated to the surveyor that he had placed his initials on the underside of the sheet to track changes. Observations over three consecutive days confirmed the presence of the resident's initials, indicating the sheets had not been changed during that time. Certified Nurse Assistants (CNAs) working on the 200 hall confirmed that bed linens were not being changed as often as required, stating that linens should be changed on bath days or as needed, but that workload prevented them from completing this task. Both the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) acknowledged that CNAs were responsible for changing linens and agreed that the resident's sheets had not been changed as required, with the DON stating that the situation was unacceptable.
Failure to Develop and Implement Comprehensive Care Plans for Elopement, Smoking, and Diet Orders
Penalty
Summary
The facility failed to develop and implement appropriate care plan interventions for four residents, resulting in deficiencies related to elopement risk, smoking, and dietary orders. For one resident with dementia and a history of behavioral disturbances, there were multiple documented incidents of attempted elopement, including leaving the facility grounds and packing belongings to go home. Despite these behaviors and a high-risk elopement assessment, an elopement risk care plan was not developed until after a significant incident occurred. Another resident with severe cognitive impairment was identified as high risk for elopement through an assessment, but no corresponding care plan was created to address this risk. A third resident, who was cognitively intact and identified as a tobacco user, was allowed to participate in supervised smoking breaks without a completed "Smoking Observation Form" or a care plan related to smoking. The required assessment and care plan were only completed after the deficiency was identified. Staff interviews confirmed that the resident was "grandfathered in" for smoking privileges, but the necessary documentation and planning were not in place prior to the surveyor's review. For a fourth resident with hemiplegia, dysphagia, and a physician-ordered mechanical soft diet, the care plan specified the correct diet, but staff failed to follow it, resulting in the resident being served a hamburger, which is not considered mechanical soft. This led to a choking incident. Staff interviews confirmed that the resident's dietary needs were documented in multiple locations, including the care plan, but the prescribed diet was not adhered to during meal service.
Failure to Follow Physician's Order for Daily Wound Care
Penalty
Summary
A deficiency was identified when staff failed to follow a physician's order for wound care treatment for one resident with a history of coronary angioplasty and moderate cognitive impairment. The physician's order specified that the resident's right-hand skin tear should be cleaned with wound cleaner, patted dry, and covered with calcium alginate and a dry dressing once daily. However, observations over several days revealed that the resident's bandage had not been changed daily as ordered, with one bandage remaining in place for multiple days. The resident reported that their dressing was changed every six days, and staff interviews confirmed that the dressing change schedule did not align with the physician's daily order. Further investigation revealed that the LPN responsible for the dressing change was unaware of the specific daily order and believed the dressing should be changed on Mondays, Wednesdays, and Fridays or as needed. The Wound Care Nurse, who typically managed these treatments, was on vacation, and the responsibility had shifted to unit nurses. The Direct Health Service confirmed that nurses are expected to follow physician orders for treatments in the absence of the Wound Care Nurse. The failure to administer wound care as prescribed resulted in noncompliance with the facility's medication administration policy and the physician's written orders.
Failure to Complete Elopement and Smoking Risk Assessments
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for two residents, specifically in the areas of elopement and smoking risk assessment. One resident with diagnoses including dementia, diabetes, and major depressive disorder exhibited repeated wandering and exit-seeking behaviors, including packing belongings and attempting to leave the facility. On two separate occasions, the resident was able to exit or attempt to exit the building, once following EMS out the front doors and another time through a propped-open smoking door. Despite these incidents and the resident's history of wandering, an elopement risk assessment was not completed after the first occurrence, and interventions were not implemented until after the second incident. Staff interviews confirmed that the resident regularly attempted to leave the building and that staff were aware of her behaviors. The LPN and housekeeper both described the resident's repeated efforts to exit, with the housekeeper discovering the resident outside the facility property during one incident. The administrator acknowledged that an elopement assessment and care plan should have been completed after the initial event but were not, and the nurse consultant confirmed that assessments should occur after such attempts or significant changes. In a separate case, another resident with a history of tobacco use and multiple medical conditions, including nicotine dependence, was identified as a smoker. However, the required smoking risk assessment and care plan were not completed until after the resident was observed smoking in the designated area. Staff interviews revealed that the resident was 'grandfathered in' to smoke at the facility, but the necessary documentation and assessment were missing from the electronic health record until after the deficiency was identified. The MDS coordinator confirmed that the assessment and care plan should have been in place but were not completed until after the oversight was discovered.
Failure to Provide Properly Prepared Mechanical Soft Diet Results in Choking Incident
Penalty
Summary
A deficiency occurred when a resident with a history of hemiplegia, hemiparesis, and dysphagia following a cerebral infarction was not provided with food prepared in accordance with their prescribed mechanical soft diet. The resident's medical records, care plan, and physician orders all indicated the need for a mechanically altered, therapeutic diet, specifically requiring ground meats. Despite these documented requirements, the resident was mistakenly served a hamburger patty, which does not meet the criteria for a mechanical soft diet, resulting in a choking incident. Staff interviews confirmed that the error occurred when the resident received their roommate's meal tray, which did not match the resident's dietary needs. The Registered Dietician clarified that mechanical soft meats are considered ground meats and that a hamburger patty is not appropriate for this diet. The Dietary Manager also confirmed the dietary error and observed the incorrect tray delivery. The incident highlights a failure in ensuring that food provided matched the resident's individualized dietary requirements as documented in their care plan and physician orders.
Improper Storage of Personal Care Items in Shared Bathrooms
Penalty
Summary
Staff failed to properly store resident personal care items in three of twelve shared bathrooms on the 200 Hall, as observed during multiple surveyor visits. Specifically, bed pans, bath basins, and urinals were found not bagged or labeled in bathrooms shared between rooms 216 and 218, 215 and 217, and 205 and 207. These observations were made on several occasions, indicating a pattern of non-compliance with the facility's policy on standard precautions, which requires that such items be handled in a manner that prevents contamination and cross-contamination. Interviews with a CNA, the ADON, and the DON confirmed that the expectation is for all urinals and bath basins to be cleaned, bagged, and labeled with the resident's name and room number. The DON acknowledged the presence of unbagged and unlabeled items in the shared bathrooms, confirming the failure to follow established infection prevention and control procedures as outlined in the facility's policy.
Failure to Provide Privacy Curtains in Shared Resident Rooms
Penalty
Summary
The facility failed to provide adequate visual privacy for residents in two shared rooms, specifically rooms 217 A and 218 B, as privacy curtains were missing in both locations. This deficiency was identified through multiple observations over several days, during which surveyors noted the continued absence of privacy curtains. Review of the facility's policy confirmed that full visual privacy during routine care and treatments is required by means of privacy curtains and closed doors. Interviews with a CNA and the DON confirmed that all shared rooms should have privacy curtains for each bed, and both acknowledged the lack of curtains in the identified rooms.
Resident Fall Due to Improper Hoyer Lift Transfer and Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with diagnoses including unspecified dementia, muscle weakness, and Alzheimer's disease, who was dependent on staff for all self-care and mobility and required two-person assistance for activities of daily living, was being transferred from a chair to a bed using a Hoyer lift. During the transfer, the lift pad strap broke, causing the resident to fall. The resident sustained a skin tear to the left lower arm and was subsequently found to have a nondisplaced transverse fracture of the mid-shaft of the right ulna after evaluation at the emergency department. Record review and staff interviews revealed that the transfer was not performed according to the resident's care requirements. The resident required two-person assistance, but at the time of the incident, only one CNA was present in the room during the transfer. The other CNA had left the room after helping attach the lift pad to the Hoyer lift, leaving the first CNA to complete the transfer alone. Additionally, the administrator confirmed that the wrong lift pad was used, and the seams of the pad broke during the transfer, directly leading to the resident's fall. Documentation from staff statements and the facility's investigation confirmed that the improper use of equipment and lack of adequate staff supervision during the transfer resulted in the accident. The incident was reported by multiple staff members, and the sequence of events was corroborated by written and verbal statements, as well as the facility's internal investigation records.
Insufficient Staffing Resulting in Missed ADL Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, specifically in assisting with activities of daily living (ADLs) such as scheduled showers. Multiple residents with intact cognition reported not receiving showers as scheduled, with some only receiving a few showers over several weeks due to lack of staff. Staff interviews confirmed that the facility was frequently short-staffed, with CNAs sometimes working alone and unable to provide showers or get residents up for therapy as required. The facility assessment indicated a required minimum of 3.48 hours per resident day (HPRD) of total nurse staffing, including specific requirements for RN and CNA hours, but these standards were not consistently met. Further interviews with nursing and administrative staff corroborated the ongoing staffing shortages, with reports of residents missing scheduled showers and therapy sessions due to insufficient staff coverage. The Director of Health Services and other staff acknowledged complaints from residents and families regarding missed showers and confirmed that staffing levels were inadequate. The facility had to close a wing due to lack of staff, and staff members, including the DHS, were required to perform direct care duties to compensate for shortages. These findings demonstrate a pattern of insufficient staffing that affected the delivery of essential care services to all residents.
Failure to Provide Scheduled Showers Due to Staffing Shortages
Penalty
Summary
The facility failed to provide scheduled showers to three residents who required assistance with activities of daily living. One resident, admitted with multiple diagnoses including paroxysmal atrial fibrillation, COPD, Parkinsonism, and muscle weakness, reported receiving only three showers during a 20-day stay, while records showed four showers in that period. Another resident with a history of cerebral infarction, hemiplegia, and osteoarthritis stated that he last received a shower five days prior to the interview, despite being scheduled for showers three times a week. A third resident, with chronic respiratory failure, COPD, and a traumatic amputation, also reported not receiving scheduled showers, attributing the missed care to staff shortages. Staff interviews confirmed that the facility was consistently short-staffed, making it difficult to provide showers as scheduled. Certified Nursing Assistants reported being unable to give showers when they were the only CNA on the floor or when there were not enough staff members. The Director of Health Services acknowledged the staffing issues and confirmed that residents were not receiving showers as scheduled, and that complaints had been received from both residents and families regarding this deficiency.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, resulting in incidents of sexual and physical abuse. One resident, identified as R84, was sexually abused by another resident, R41, who had a history of inappropriate sexual behavior. Despite this history, R41 was not adequately monitored or managed, leading to an incident where R41 was found rubbing R84's genitals, legs, and feet. The staff intervened and moved R84 to another room, but the incident was not properly documented or reported to the necessary authorities, including psychiatric services, for further evaluation and intervention. Another incident involved a Certified Nursing Assistant (CNA) identified as AA, who physically and verbally abused a resident, R14. The CNA was witnessed hitting R14 on the arm and using inappropriate language to get the resident out of bed. Despite being witnessed by other staff members, the incident was not immediately reported to the Director of Nursing or law enforcement, and the CNA received only a written reprimand. This lack of immediate and appropriate response highlights a failure in the facility's abuse prevention and reporting protocols. The facility's policy on abuse prohibition was not effectively implemented, as evidenced by the delayed response to these incidents and the lack of proper documentation and follow-up. Interviews with staff revealed a lack of awareness and training on monitoring and reporting abuse, contributing to the ongoing risk to residents. The facility's failure to address these deficiencies promptly resulted in an Immediate Jeopardy situation, indicating a serious threat to resident safety.
Failure to Investigate Alleged Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation into allegations of potential sexual abuse involving two residents, R84 and R41. The investigation lacked interviews with the victim, other staff, or residents who might have witnessed or been affected by the incident. The facility's policy on abuse prohibition mandates immediate reporting and investigation of such allegations, but there was no evidence of compliance with these procedures. The incident involved R41, who had a history of inappropriate sexual behavior, being observed in a compromising situation with R84, who had severe cognitive impairment. The documentation related to the incident was insufficient, consisting of only two sheets of paper, one of which was an undated, unsigned handwritten statement. There was no documented assessment of the residents involved at the time of the incident, nor were the physician or local police notified. Additionally, there was no evidence of psychiatric evaluations or written statements from witnesses. The facility's failure to follow its own procedures for investigating abuse allegations was evident in the lack of comprehensive documentation and follow-up actions. Interviews with facility staff, including the Administrator and Director of Nursing, revealed a lack of awareness and documentation regarding the incident. The new Administrator, who had only been in the position for two weeks, was unable to locate any additional documents related to the incident. The Licensed Practical Nurse on duty at the time of the incident could not recall specific details or whether a statement was made. The Social Services worker was not informed to monitor the residents for any negative effects from the incident. This lack of thorough investigation and documentation highlights the facility's noncompliance with regulatory requirements, resulting in an Immediate Jeopardy situation.
Failure to Develop Care Plans for Abuse and Elopement
Penalty
Summary
The facility failed to develop and implement care plans for three residents, leading to a deficiency in meeting the residents' needs. Resident R84, who had severe cognitive impairment and a history of unspecified dementia and psychosis, was sexually abused by another resident, R41. Despite the incident being documented, no care plan or interventions were put in place to address the abuse. The Social Services staff reported not being informed to develop a care plan for abuse or to monitor the resident for any negative effects from the incident. Resident R14, who had diagnoses including dementia and kidney failure, experienced verbal and physical abuse from a Certified Nursing Assistant. The abuse involved the CNA using profanity and hitting the resident. However, no care plan was created to address the abuse, and the Social Services staff indicated that the resident was not considered a target for abuse, which contributed to the lack of a care plan. Resident R115, with severe dementia and anxiety disorder, was assessed for moderate risk of wandering and elopement. Despite being placed in a secure unit, the resident eloped from the facility. The facility's records showed no care plan addressing elopement and safety precautions. The RN Supervisor found the resident outside the facility, and the Administrator was unaware of the missing care plans for both abuse and elopement, indicating a lack of communication and oversight in care planning.
Failure to Oversee Abuse Prevention Program
Penalty
Summary
The facility administration failed to effectively oversee an abuse prevention program, resulting in a situation where residents were not adequately protected from abuse. Specifically, the administration did not monitor, supervise, or address the sexually aggressive behavior of a resident with a known history of such behavior, leading to the sexual abuse of another resident. This incident caused psychosocial trauma to the victim. Additionally, the facility did not protect another resident from verbal abuse by staff. The administration also failed to investigate, correct, and prevent allegations of abuse between residents. A thorough investigation was not completed for a reportable incident involving sexual abuse, and there was no evidence that the previous administrator took necessary actions such as contacting medical professionals or updating care plans. This lack of action left the facility unable to address and mitigate the risks associated with resident-to-resident abuse. Furthermore, the facility did not develop and implement person-centered comprehensive care plans related to abuse for the affected residents. One resident did not have a care plan addressing the abuse they suffered, and another resident's care plan did not address identified elopement risks. Interviews with staff revealed a lack of awareness and communication regarding the need for these care plans, indicating a breakdown in the facility's processes for ensuring resident safety and care.
Unauthorized Administration of Melatonin to Residents
Penalty
Summary
The facility failed to ensure that two residents, R136 and R302, were given medication only with a physician's order. This deficiency was identified when an LPN administered her personal melatonin to these residents, resulting in them becoming lethargic. The facility's policies on medication administration and abuse prohibition were not adhered to, as the LPN did not verify the correct medication or have a physician's order before administering the melatonin. Resident R136, who had severe cognitive impairment and a history of dementia, major depressive disorder, and other conditions, did not have a physician's order for melatonin in their January 2024 records. Similarly, Resident R302, with moderate cognitive impairment and a history of dementia and other conditions, also lacked a physician's order for melatonin. Despite this, the LPN was witnessed administering melatonin to these residents, which was not documented in their electronic Medication Administration Records (eMAR). The incident was reported by staff who observed the LPN with melatonin on the medication cart and witnessed her administering it to residents. The LPN admitted to having melatonin on her cart, claiming it was for personal use, but denied using it on residents. However, staff interviews and video surveillance provided evidence that the LPN was administering melatonin without orders, leading to the residents' lethargy.
Infection Control Deficiencies in Linen and Equipment Handling
Penalty
Summary
The facility failed to adhere to infection control standard practices, leading to potential cross-contamination of linens and resident equipment. Observations on Hall OB revealed that a dirty linen cart and a clean linen cart were positioned side by side, and a CNA was seen transferring items between the two carts. Similar issues were noted on Turtle Dove Hall, where a clean linen cart was placed between trash barrels containing dirty items, and a bath shower bed was positioned next to a dirty linen barrel. Staff members, including a CNA and a housekeeping tech, were unaware of the need to separate clean and dirty items, despite having received training on infection control. Additionally, a standup lift on Turtle Cove Hall was observed with a buildup of a dark greyish substance, and it was used to transfer a resident without being cleaned. The Director of Nursing confirmed the issues with the lift and the positioning of the linen carts and trash barrels, acknowledging the risk of cross-contamination. The facility's Administrator also expressed concern over these findings, noting that infection control training had been provided to staff shortly before the surveyor's observations. However, no policy related to these concerns was provided during the survey.
Unauthorized Medication Found in Resident's Room
Penalty
Summary
The facility failed to ensure that a resident in the Memory Care Unit did not have unsecured unauthorized medications stored at the bedside. This deficiency was identified during an observation where a prescription bottle of Nyamyc, an antifungal powder, was found on the sink counter in the bathroom of a resident's room. The medication was labeled for another resident, indicating a lapse in medication management and security. The resident in question had a diagnosis of dementia with moderate cognitive impairment and was assessed for wandering behaviors, which further underscores the importance of secure medication storage. Licensed Practical Nurse (LPN) LLL confirmed that no residents in the Memory Care Unit had been assessed to self-administer medications, and acknowledged that the medication should not have been in the resident's room. The Director of Nursing (DON) and the facility Administrator both confirmed that nurses are expected to conduct rounds to monitor for medications in residents' rooms. The presence of the medication in the resident's room was unexplained, and it was acknowledged that the medication should not have been left out, highlighting a failure in the facility's medication management procedures.
Delayed Reporting of Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency (SA) in a timely manner, as required by their policy. The policy mandates that the Abuse Coordinator or designee must notify the State Survey Agency immediately, but not longer than two hours after an allegation is made if it involves abuse or results in serious bodily injury. In this case, the incident involved a Certified Nursing Assistant (CNA) who was physically and verbally abusive to a resident. The incident was observed by two CNA students and involved the CNA hitting the resident on the arm and using profanity. The incident occurred on June 7, 2023, but was not reported to the SA until June 13, 2023, which is beyond the required reporting timeframe. The former Director of Nursing (DON) confirmed that the incident was reported to local law enforcement and the SA on June 8, 2023, but there is no evidence to support that the SA was notified before June 13, 2023. The Administrator also confirmed the late reporting of the incident. This delay in reporting is a violation of the facility's policy and the regulatory requirement to report such incidents promptly to the appropriate authorities.
Failure to Develop Discharge Plans for Residents
Penalty
Summary
The facility failed to develop a discharge plan of care for seven residents, as identified through record reviews, staff interviews, and facility policies. The facility's Discharge Planning Policy and Nursing Care Planning policy were not adhered to, resulting in the absence of documented discharge plans for residents R78, R81, R84, R98, R115, R104, and R454. These residents had participated in discharge planning and were expected to remain in the facility, yet no formal discharge care plans were documented in their Electronic Medical Records (EMR). The residents involved had various medical conditions, including cerebral palsy, dementia, respiratory failure, and hypertension, among others. Despite their participation in discharge planning, the facility did not document any discharge plans or care plans for these residents. For instance, R78, who has cerebral palsy and functional quadriplegia, was expected to remain in the facility, but no discharge plan was documented. Similarly, R454 was expected to discharge to a community facility, but the discharge care plan and summary were not completed. Interviews with facility staff revealed a lack of clarity and responsibility regarding the completion of discharge care plans. Social Services staff acknowledged the omission of discharge care plans for the residents and expressed uncertainty about who was responsible for completing the discharge summary. The facility administrator indicated that the discharge summary and care plan should be completed by nursing staff or a social worker, but this was not done for the residents in question.
Incomplete Discharge Summary and Medication Reconciliation
Penalty
Summary
The facility failed to provide a completed discharge summary with a recapitulation of the resident's stay for a discharged resident, identified as R454. The resident was admitted with a hip fracture and a Stage 2 Pressure Ulcer and was discharged on 10/13/2023. The discharge summary indicated that the resident was to be discharged home with medications, home health services, and follow-up appointments with healthcare providers. However, there was no evidence that a medication list was provided to the resident at discharge, nor was there a post-discharge plan of care developed. Interviews with facility staff, including the Financial Counselor, RN Supervisor, and MDS Coordinator, confirmed the omission of a complete discharge summary in the resident's records. The RN Supervisor, who discharged the resident, was unaware of the requirement to reconcile medications with the resident or family and did not complete the necessary discharge summary. The MDS Coordinator noted that the discharge form was accessible in the EMR system but was not completed. The facility Administrator confirmed that the nursing staff or social worker should have completed the discharge summary and post-discharge plan of care, with all medications signed off by the discharge nurse with the family.
Failure to Provide PROM Treatment for Resident with Limited ROM
Penalty
Summary
The facility failed to provide appropriate passive range of motion (PROM) treatment for a resident with limited range of motion in the right upper extremity, specifically the right hand. The resident, who was admitted with diagnoses including cerebral palsy and functional quadriplegia, was referred to skilled occupational therapy due to increased stiffness in the right hand. An occupational therapist evaluated the resident and recommended a wrist hand splint and PROM/AAROM exercises to address the stiffness. However, the facility did not ensure that these therapeutic interventions were consistently implemented, as the resident did not receive the necessary PROM treatment. Interviews with facility staff revealed a lack of a structured restorative program and inadequate communication regarding the resident's therapy needs. A CNA assigned to restorative services reported that her duties were primarily focused on ambulation and weighing residents, with limited involvement in providing range of motion exercises. The Director of Nursing expected that range of motion exercises would be performed during resident baths and positioning, but this was not consistently done. The OT Director was unaware of the closure of the restorative program and confirmed that therapeutic interventions could have prevented further contractures. The resident's decline in hand function was not addressed in the facility's morning meetings, indicating a breakdown in communication and follow-up care.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to ensure proper storage of respiratory equipment for two residents receiving respiratory treatment. For one resident, the AutoPap mask was observed lying on the bedside dresser without being stored in a plastic bag as required by the facility's policy. Additionally, a container of distilled water used with the AutoPap machine was not labeled with an open date. Interviews with staff revealed a lack of clarity regarding responsibility for maintaining respiratory supplies, with a CNA indicating that nurses were responsible for the equipment. Another resident's nebulizer and Trilogy masks were also found not properly stored while not in use. The resident had a history of chronic respiratory failure and was non-compliant with using the Trilogy machine. Observations confirmed that the masks were left on the bedside dresser without being placed in a plastic bag. Interviews with staff, including a CNA and an LPN, revealed that the staff were aware of the storage requirements but failed to ensure compliance. The LPN admitted to not noticing the improper storage and acknowledged the potential risk of microbial contamination. The Director of Nursing confirmed that the expectation was for supplies to be properly stored and labeled, and that all nurses were responsible for ensuring compliance with these regulations. The failure to adhere to the facility's policies on storing respiratory equipment had the potential to increase the risk of respiratory complications for the residents involved.
Failure to Comply with PRN Psychotropic Medication Regulations
Penalty
Summary
The facility failed to ensure compliance with regulations regarding the use of PRN psychotropic medications, specifically Ativan, for a resident identified as R111. The resident, who was admitted with diagnoses including dementia with behavioral disturbances and a psychotic disorder, was readmitted to the facility from the hospital with a PRN order for Ativan. The order did not include a stop date, and the medication was administered multiple times beyond the 14-day limit without documented rationale or reassessment by a provider. Interviews with facility staff, including the LPN, DON, ADON, and RN Supervisor, revealed a lack of awareness and understanding of the regulations requiring PRN psychotropic medications to have a stop date and be reassessed for continued use. The DON and ADON admitted they were unaware of the need for a stop date or reassessment, and the RN Supervisor, who was new to the facility, was uncertain about the requirements. The pharmacy consultant had provided recommendations to address the PRN Ativan usage, but these were not acted upon, and the necessary documentation and orders were not updated in the resident's medical record. The deficiency was further compounded by communication lapses within the facility. The RN Supervisor received a signed recommendation from the physician to continue the PRN Ativan for 180 days but failed to document this in the progress notes or update the order with a stop date. The recommendation was placed on a clipboard in the DON's office and was not followed up due to the RN Supervisor's schedule and responsibilities. This oversight resulted in the continued administration of Ativan without proper documentation or justification, violating the facility's policy and regulatory requirements.
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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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