Woods At Sparta Of Journey Llc, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Sparta, Georgia.
- Location
- 60 Providence Street, Sparta, Georgia 31087
- CMS Provider Number
- 115397
- Inspections on file
- 17
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Woods At Sparta Of Journey Llc, The during CMS and state inspections, most recent first.
A resident sustained a burn from an unsupervised e-stim treatment, and the facility failed to report or document the incident promptly. Additionally, power strips were improperly placed on the floor and bedside tables, posing hazards to residents. Staff interviews revealed a lack of awareness and communication regarding safety protocols.
A resident suffered a burn on the right leg due to improper use of an e-stim device by physical therapy staff who were not adequately trained. The staff member applied the device and left the room, resulting in the resident experiencing intense burning and removing the device to find burn marks. Interviews revealed that the facility did not provide training or competency checks for the e-stim device, relying on staff's prior schooling. The facility began training after the incident, but the delay in education was unexplained.
The facility's dietary staff failed to follow proper food safety protocols, including preventing wet nesting of steam table pans, storing food off the floor, and correctly using the three-compartment sink for sanitizing dishware. These deficiencies were confirmed by the Dietary Manager and observed during a survey.
A facility failed to maintain a dumpster, resulting in liquid waste leaking onto the ground due to a missing plug. Despite being aware of the issue, the facility's staff, including the DM and IMD, confirmed the ongoing leakage over several days. The Administrator noted the dumpsters were city-owned and lacked a specific waste disposal policy.
The facility failed to maintain effective infection control in its laundry operations. Observations revealed that laundry staff did not use PPE and transported clean linens uncovered, violating facility policies. Interviews indicated a lack of training and awareness among staff and management regarding infection control procedures, leading to potential cross-contamination risks.
A resident in a long-term care facility developed sores on the right lower leg, believed to be from an e-stim machine used during physical therapy. Despite the resident's denial of the sores' origin, the Physical Therapy Assistant documented the observations but failed to communicate them to the nursing staff or the Administrator. Consequently, the physician or Nurse Practitioner was not notified until 11 days later, when the resident's condition had worsened, requiring antibiotic treatment. Interviews revealed a breakdown in communication and documentation, with staff failing to complete an incident report or ensure proper notification.
The facility was found deficient in maintaining a safe, clean, and comfortable environment, with issues such as missing floor tiles, a bare lightbulb, chipped and peeling paint, and discolored ceiling tiles. Interviews revealed a lack of awareness and documentation of these maintenance issues, with the facility in the process of recruiting a permanent Maintenance Director.
The facility did not conduct pre-employment reference checks for eight employees, including key staff like the Administrator and DON, as required by their policy on Abuse, Neglect, and Exploitation. This oversight was confirmed through interviews and a review of employee files, although no abuse or neglect concerns were identified at the time.
Two residents with serious mental disorders were not referred for a PASARR Level II assessment upon admission or within 30 days of a new diagnosis. One resident with PTSD had an incomplete PASARR Level I, and no Level II assessment was conducted. Another resident with multiple diagnoses, including anxiety disorder, had an incomplete PASARR Level I, and no Level II assessment was completed. The responsibility for ensuring these assessments lies with the social worker, who was unavailable for comment.
A resident with schizophrenia was admitted to a facility without a required PASARR Level II assessment, despite facility policy mandating such coordination for mental disorders. The resident's PASARR Level I status was marked as Pending, indicating the need for further assessment, but this was not completed, as confirmed by the DON and Business Office Manager.
The facility failed to develop and implement comprehensive care plans for two residents. One resident did not have a care plan for pain management despite having diabetes with neuropathy and documented pain. Another resident's care plan for oxygen therapy was not followed, despite their need for respiratory support due to conditions like COPD and sleep apnea. These deficiencies were confirmed by the MDS/Care Plan Coordinator and the DON.
A facility failed to update a resident's care plan to reflect a change in code status from Full Code to DNR, as indicated by the POLST document. The MDS Coordinator acknowledged the oversight, and the DON explained that the SSD was responsible for reporting code status changes to the MDS Coordinator.
The facility failed to provide proper respiratory care for two residents. One resident did not receive continuous oxygen as ordered, with the equipment left exposed. Another resident's nebulizer mouthpiece was improperly stored, increasing infection risk. Staff were aware of the protocols but did not comply.
A facility failed to implement a 14-day stop date for a resident's PRN Ativan prescription, as required by their policy. The medication, used for anxiety, was administered multiple times over an extended period without a documented rationale for extending the order. The DON admitted the oversight despite audits to ensure compliance.
The facility did not follow established menus and failed to notify the RD of meal substitutions, affecting residents on mechanical soft ground and puree diets. Instead of the posted menu, residents received meals with unapproved substitutions, such as brown gravy on chicken and mashed potatoes instead of puree cabbage. The RD was not informed of these changes, contrary to facility policy.
The dietary staff failed to follow the standardized recipe for fried chicken, affecting nine residents who required puree and mechanical soft ground consistencies. Instead of using fried chicken as indicated on the menu, plain steamed diced chicken was used, compromising the nutrient value of the meal. The Dietary Manager and Registered Dietitian were unaware of this substitution, leading to a deficiency in meal preparation.
Failure to Ensure Resident Safety and Proper Supervision
Penalty
Summary
The facility failed to ensure the safety of three residents, resulting in actual harm to one resident, R14, who sustained a burn from an electrical stimulation (e-stim) treatment. The physical therapy staff did not adequately supervise the e-stim treatment, leading to a burn on R14's right leg. Despite the resident's report of the burn to the physical therapy assistant, the incident was not communicated to the nursing staff or documented in the resident's medical record until 11 days later. The resident continued to receive e-stim treatments even after the burn was identified, and the physician was not notified promptly. Additionally, the facility did not maintain a safe environment for residents R14, R15, and R30, as power strips were found on the floor and bedside tables, posing potential hazards. These power strips were used with medical equipment, such as oxygen concentrators and electrical beds, without being properly secured or mounted. Staff interviews revealed a lack of awareness and communication regarding the proper placement and safety requirements for surge protectors. The facility's failure to adhere to its own policies on incident reporting and safety precautions contributed to the deficiencies. The lack of immediate action and communication among staff members regarding the burn incident and the improper use of power strips demonstrated a significant oversight in ensuring resident safety and compliance with established protocols.
Lack of Training Leads to Resident Harm from E-Stim Device
Penalty
Summary
The facility failed to ensure that physical therapy staff were adequately informed or educated before applying an electronic medical device for electrical stimulation treatment (e-stim) on a resident, resulting in actual harm. The incident involved a resident who sustained a burn on the right leg with 100% slough in the wound bed after a physical therapy staff member applied the e-stim device and left the room. The resident, who was cognitively intact, reported that the device began to burn intensely, prompting him to remove it and discover three burn marks. The resident expressed concern that staff were using residents as test subjects without proper training. Interviews with facility staff revealed a lack of training and competency checks for the e-stim device. The Physical Therapy Manager admitted that the therapy staff had not received training or education on the device within the facility, assuming that their schooling sufficed. The Physical Therapy Assistant confirmed the absence of formal training, relying on her school training and personal experimentation. The Administrator acknowledged the need for skill checks to ensure staff competency, and the Regional Rehabilitation Manager confirmed that no training was provided before the incident. The facility began educating the physical therapy department after the incident, but the reason for the delay was not provided.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The dietary staff at the facility failed to adhere to proper food safety and sanitation protocols, as observed during a survey. The staff did not prevent wet nesting of steam table pans, which can lead to bacterial growth. During an inspection, it was found that the inside of the top pans in stacks of steam table pans were wet, indicating they were not completely air-dried before stacking. The Dietary Manager confirmed this observation and acknowledged that the pans should have been air-dried completely before being stacked. Additionally, the facility did not store food items properly in the dry storage area, as cases of food were found directly on the floor. The Dietary Manager admitted that the food items were left on the floor due to a recent grocery delivery and a lack of time to store them properly. Furthermore, the staff did not follow the correct procedure for using the three-compartment sink for sanitizing dishware. A dietary staff member was observed not immersing dishware in the sanitizing solution for the required 60 seconds, which was confirmed by the staff member and the Dietary Manager.
Improper Dumpster Maintenance Leads to Waste Leakage
Penalty
Summary
The facility failed to properly maintain one of its two dumpsters, leading to a deficiency in waste management. Observations revealed that the dumpster closest to the building was missing a plug at the bottom, resulting in a liquid substance actively dripping onto the asphalt ground. This issue was first observed on 8/9/2024 and continued to be present during subsequent observations on 8/10/2024 and 8/11/2024. The Dietary Manager confirmed the absence of the plug and the active leakage during interviews conducted on these dates. The facility's Administrator and Interim Maintenance Director were made aware of the issue, with the Administrator noting that the dumpsters were city-owned and maintained, and that there was no existing policy regarding dumpsters or waste disposal. The Interim Maintenance Director confirmed that the plug likely dislodged during the last garbage pick-up and had contacted the waste management company to request a replacement. Despite these communications, the issue persisted over several days, indicating a lapse in timely corrective action.
Infection Control Deficiency in Laundry Handling
Penalty
Summary
The facility failed to maintain an effective infection control program, particularly in the handling, storage, and processing of linens. During a tour of the laundry area, it was observed that the industrial washer had accumulations of chemical residue and dust, and the laundry staff was not using personal protective equipment (PPE) while handling both dirty and clean laundry. Additionally, clean clothing was found hanging on an uncovered rack, ready for distribution, which is against the facility's infection control policies. Interviews with the laundry staff and management revealed a lack of awareness and training regarding infection control procedures. Laundry Aide GG admitted to not wearing PPE and was unaware of the requirement to cover clean clothing racks. The Laundry Manager, who was new to the position, also lacked training and was unaware of the need to cover clean clothing racks or the requirement for staff to wear PPE. The Director of Nursing confirmed that all linen should be covered before leaving the laundry and that staff should wear gloves and gowns when handling soiled linen. Further observations showed that clean linen was transported in uncovered baskets and placed next to dirty linen carts, which violates the facility's policy of keeping clean and dirty linens separate. Interviews with other laundry aides confirmed that they had never covered laundry during transport and did not wear PPE when handling contaminated or clean linen. The Infection Prevention Nurse and the Administrator reiterated the importance of separating clean and dirty linen and the requirement for PPE, highlighting a systemic issue in the facility's infection control practices.
Failure to Timely Notify Health Agent of Resident's Burn
Penalty
Summary
The facility failed to timely notify the health agent of a significant change related to a burn for a resident, identified as R14, which was a deficiency found during the survey. The facility's policy requires notifying the resident, their physician, and a family member or legal representative when there is a significant change in the resident's condition. In this case, R14, who was cognitively intact with a BIMS score of 14, developed sores on the right lower leg, believed to be from an e-stim machine used during physical therapy. Despite the resident's denial of the sores' origin, the Physical Therapy Assistant (PTA) documented the observations but failed to communicate them to the nursing staff or the Administrator. Consequently, the physician or Nurse Practitioner was not notified until 11 days later, when the resident's condition had worsened, requiring antibiotic treatment. Interviews with facility staff revealed a breakdown in communication and documentation. The PTA informed the Physical Therapy Manager of the burn, but neither completed an incident report nor ensured the nursing staff was aware. The Assistant Director of Nursing confirmed the absence of documentation or an event report related to the burn in the electronic medical record. The Physical Therapy Manager admitted to assuming the PTA had reported the incident to nursing and acknowledged the oversight in not following up. The Medical Director was aware of the burn but uncertain about the timeliness of the notification, emphasizing the need for immediate reporting and frequent monitoring of such injuries.
Deficiencies in Facility Maintenance and Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment in several resident rooms and a common area, as observed during a survey. Specific deficiencies included missing floor tiles in multiple rooms, a bare lightbulb without a cover in a shared restroom, chipped paint on baseboards, peeling paint exposing drywall, and discolored ceiling tiles in the Resident Dining Room. These issues were identified through observations conducted on different dates and times, highlighting the facility's inability to adhere to its own policies on maintenance and preventative maintenance. Interviews with the facility's Administrator, Interim Maintenance Director, and Corporate Director of Procurement, Information Technology, and Maintenance revealed a lack of awareness and documentation regarding the maintenance issues. The Administrator confirmed the need for repairs and expressed expectations for a home-like environment, while the Interim Maintenance Director admitted to conducting daily observational rounds without documentation. The Corporate Director acknowledged the need for timely repairs and was in the process of finding matching tiles for the missing ones. The facility was also in the process of recruiting a permanent Maintenance Director.
Failure to Conduct Pre-Employment Reference Checks
Penalty
Summary
The facility failed to conduct pre-employment reference checks for eight out of 60 employees, as required by their policy on Abuse, Neglect, and Exploitation. This policy mandates that potential employees undergo background, reference, and credentials checks to screen for any history of abuse, neglect, exploitation, or misappropriation of resident property. The absence of these checks was discovered during a review of employee files, which revealed that key staff members, including the Administrator, Director of Nursing, and several nurses, were hired without the necessary reference checks. Interviews with the Business Office Manager and the Administrator confirmed the lack of documentation for these reference checks. The Business Office Manager, who was temporarily covering for the Human Resource Director, was unable to locate the required documents. The Administrator acknowledged that the Human Resource Director was responsible for ensuring the completion and maintenance of new hire documents, including reference checks. Despite the deficiency, there were no identified concerns related to abuse or neglect within the facility at the time of the report.
Failure to Conduct PASARR Level II Assessments
Penalty
Summary
The facility failed to ensure that two residents with serious mental disorders were referred for a Level II PASARR assessment upon admission or within 30 days of a new diagnosis. Resident R34 was admitted with a diagnosis of PTSD, but the PASARR Level I request did not document this diagnosis, and no PASARR Level II assessment was conducted. The Director of Nursing confirmed the absence of a PASARR Level II in R34's clinical record and acknowledged that the PASARR Level I should have included the PTSD diagnosis. The Social Service Director, responsible for reviewing PASARR Level I and resident diagnoses, was unavailable for comment. Resident R35 was admitted with diagnoses including dementia, depression, anxiety disorder, and delusional disorder. However, no PASARR Level II assessment was completed, and the PASARR Level I assessment was incomplete, with sections left blank. Interviews with the Business Office Manager and the Director of Nursing revealed that the responsibility for ensuring a PASARR Level II assessment lies with the social worker, who was also unavailable for an interview. The Director of Nursing noted that R35's diagnosis of anxiety disorder warranted a PASARR Level II assessment.
Failure to Complete PASARR Level II Assessment for Resident with Schizophrenia
Penalty
Summary
The facility failed to ensure that a resident with a serious mental disorder was referred for a Level II PASARR assessment upon admission or within 30 days of a new diagnosis. The resident, identified as R19, was admitted with a diagnosis of schizophrenia, which was documented in the electronic medical record and the Minimum Data Set (MDS). Despite this, the facility did not have a PASARR Level II assessment on file for the resident, as confirmed by the Director of Nursing (DON) and the Business Office Manager. The facility's policy requires coordination with the PASARR program to ensure appropriate care for residents with mental disorders. However, the Social Services Director, responsible for tracking PASARR screening status, did not ensure a Level II assessment was completed for R19. The PASARR Level I request, dated 5/5/2017, indicated a diagnosis of schizoaffective disorder, and the status was marked as Pending, suggesting the need for a Level II assessment. The absence of this assessment was verified by the DON, who acknowledged the potential risk of the resident not receiving necessary services.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, R14 and R15, as required by their policy. For R14, the facility did not create a care plan addressing pain management despite the resident's documented diagnoses of type 2 diabetes mellitus with diabetic neuropathy and generalized muscle weakness. The resident's quarterly MDS indicated the presence of pain, and a physical therapy evaluation outlined a treatment plan to manage this pain. However, the care plan lacked any mention of pain management or the specific diagnosis, which was confirmed by the MDS/Care Plan Coordinator and the Director of Nursing (DON). For R15, the facility failed to implement the care plan for oxygen therapy. The resident's medical record included diagnoses such as acute and chronic respiratory failure, COPD, and obstructive sleep apnea, with the quarterly MDS documenting the receipt of oxygen therapy. Although the care plan noted the risk of respiratory decline and included interventions for respiratory treatments, it was not followed as the resident did not receive oxygen as ordered. This oversight was verified by both the MDS/Care Plan Coordinator and the DON, who acknowledged the care plan was not being adhered to.
Failure to Revise Care Plan for Code Status Change
Penalty
Summary
The facility failed to revise the care plan for a resident who experienced a change in code status. The facility's policy on Comprehensive Care Plans requires that care plans be reviewed and revised by the interdisciplinary team following each comprehensive and quarterly Minimum Data Set (MDS) assessment. However, a review of the resident's care plan revealed that it was not updated to reflect the change from Full Code status to Do Not Resuscitate (DNR), despite the Physician Orders for Life-Sustaining Treatment (POLST) document indicating a change to Allow for Natural Death. The MDS Coordinator acknowledged the oversight during an interview, and the Director of Nursing explained that the Social Service Director was responsible for handling code status changes and reporting them to the MDS Coordinator.
Deficient Respiratory Care Practices
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for two residents. For one resident with acute and chronic respiratory failure, heart failure, COPD, and obstructive sleep apnea, the facility did not administer oxygen as ordered. Observations revealed that the resident was not receiving the prescribed continuous oxygen, and the oxygen tubing and nasal cannula were left exposed to the environment. There was no documentation of the resident refusing or removing the oxygen, despite the order for continuous administration. For another resident with dyspnea and COPD, the facility did not properly store the nebulizer mouthpiece. Observations showed that the nebulizer cup and mouthpiece were left unbagged and exposed to the environment. Interviews with staff confirmed awareness of the requirement to store respiratory equipment in a plastic bag to prevent infection, yet the equipment was not stored properly. The resident reported that the storage bag had been missing for a few days, and staff interviews confirmed the lack of compliance with storage protocols.
Failure to Implement 14-Day Stop Date for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure a stop date was implemented for psychotropic medications, specifically for a resident prescribed Ativan for anxiety. The facility's policy requires that PRN psychotropic drugs have a stop date not exceeding 14 days unless the attending physician documents a rationale for extending the order. However, a review of the resident's physician orders revealed an indefinite end date for Ativan, which was administered multiple times over a period exceeding 14 days. The Director of Nursing acknowledged that the oversight occurred despite audits conducted to ensure compliance with the policy.
Failure to Follow Established Menus and Notify RD of Substitutions
Penalty
Summary
The facility failed to adhere to established menus and did not notify the Registered Dietitian (RD) of meal substitutions, affecting residents on mechanical soft ground and puree diets. The facility's policy, titled Therapeutic Diet Orders, mandates that residents receive foods in the appropriate form and nutritive content as prescribed by a physician or assessed by the interdisciplinary team. However, during an observation, it was noted that the lunch meal served did not match the posted menu. Instead of fried chicken, black eye peas, collard greens, and cornbread, residents on a mechanical soft ground diet received ground plain chicken with brown gravy, boiled cabbage, blackeye peas, and cornbread. Residents on a puree diet received plain puree chicken with brown gravy, puree blackeye peas, and mashed potatoes. Interviews revealed that the Dietary Manager (DM) did not notify the RD of several menu changes, including the addition of brown gravy to the chicken, the substitution of mashed potatoes for puree cabbage, and the omission of pureed cornbread. The RD confirmed that she was only informed about the substitution of cabbage for collard greens. The DM admitted to not having the option to purchase chicken gravy and using brown gravy instead, as well as not having time to puree cabbage. The RD emphasized that dietary staff should serve the menu as posted and notify her of any modifications, which was not done in this instance.
Failure to Follow Recipe for Fried Chicken
Penalty
Summary
The dietary staff at the facility failed to follow the standardized recipe for fried chicken, compromising the nutrient value of the meal served to residents. The deficiency affected six residents who required puree consistency and three residents who required mechanical soft ground consistency from a total of 40 residents receiving an oral diet. The menu indicated that fried chicken was to be served, but instead, plain steamed diced chicken was used. This practice was observed during a survey, where Dietary [NAME] II was seen using steamed diced chicken instead of fried chicken for the puree consistency meal. The dietary staff member was unaware of the recipe requirements and had been using plain chicken, believing it was acceptable. The Dietary Manager (DM) confirmed the use of plain steamed chicken instead of fried chicken and admitted that the facility's Registered Dietitian (RD) had not been informed of this substitution. The RD expected the dietary staff to follow the recipes and indicated that actual fried chicken should have been used to ensure proper nutrient value and taste. The RD was not aware of the changes made by the dietary staff, and the DM assumed that using any form of chicken would suffice. This lack of communication and adherence to the recipe led to the deficiency in meal preparation.
Latest citations in Georgia
Surveyors found that clean linens and personal clothing were stored and staged in close proximity to the dirty laundry area, with an open door between the clean and soiled sides and all washer and dryer doors open. Clean resident clothes, unlabeled garments, and bagged items were placed next to dryers and directly in front of the dirty linen room, and dirty barrels had to be pushed past racks of clean clothing to reach the washers, contrary to facility policies requiring separation of clean and soiled linens. Environmental staff believed keeping doors open and covering dirty barrels reduced infection spread, while the Environmental Services Director, IP nurse, and Administrator acknowledged that the dirty room door should be closed, linens should not be on dirty barrels, and clean resident clothing should not be stored in that location.
A resident with a suprapubic catheter, colostomy, sacral wound, and dependence on staff for bathing and hygiene was care planned for Enhanced Barrier Precautions (EBP), including use of PPE during high-contact care. During observed catheter care and a bed bath, a CNA wore only gloves and did not don a gown, despite EBP signage and a star posted on the door and PPE supplies available outside the room. In interviews, the CNA admitted forgetting to wear a gown and not recognizing additional required actions, while the IP nurse and DON confirmed that staff had been educated that gowns and gloves are required for high-contact care involving indwelling devices and wounds under the facility’s EBP policy.
A resident with multiple neurologic and psychiatric diagnoses, intact cognition, and unilateral functional limitations was found with an open box of lubricant eye drops stored at the bedside without any documented assessment for self-administration or prescriber’s order for self-administration or bedside storage, contrary to facility policy. Observations on multiple days confirmed the eye drops remained at the bedside, while staff interviews showed that CNAs and the IP recognized that residents were generally not to self-administer medications and that bedside medications required assessment and orders. The Administrator confirmed that the resident should not have had eye drops in the room and that residents with bedside medications are typically assessed for self-administration, and staff acknowledged that unsecured eye drops at the bedside could be accessed or ingested by other residents and cause harm.
The facility failed to maintain a safe, clean environment when multiple ceiling tiles throughout the building, including above a resident’s bed, near the nurses’ station, in a glass day room above a resident’s chair, and in a main hall, were observed with brown circular stains, bulging, and a white moldy substance. The Maintenance Director confirmed the stained and bulging tiles, acknowledged the risk that tiles above a resident’s bed could fall, and attributed the condition to rain-related roof leaks. The Administrator also confirmed that roof leaks and recent rainfall caused the brownish stains despite her reported daily rounds.
A resident with severe cognitive impairment, on hospice and fully dependent for ADLs, was sexually abused when another cognitively impaired male resident with a long-standing history of sexually inappropriate behavior toward female residents entered her room and placed his hand inside her pants. The abusing resident had multiple dementia and psychiatric diagnoses, was care planned for sexually inappropriate behaviors with prior documented incidents, and was on psychotropic medication for OCD-related sexual obsession. Despite these known risks and existing care plan interventions, he was able to access the female resident’s room and make inappropriate physical contact, and the facility’s investigation substantiated the abuse.
Surveyors found that the facility failed to develop and implement complete, person-centered care plans for two residents. One resident was receiving an antipsychotic (Haloperidol) for schizophrenia with associated behavior and side-effect monitoring orders, but there was no corresponding care plan addressing antipsychotic use or its indication. Another resident had an indwelling Foley catheter for neurogenic bladder related to prostate cancer, with goals to prevent catheter-related trauma; however, the care plan omitted key interventions such as balloon volume parameters and use of a leg strap or securement device, despite physician orders requiring a leg strap and observations showing the catheter positioned under the leg without securement. An MDS coordinator and the administrator acknowledged that required interventions and standard catheter care components were missing from the care plans.
A resident with a history of resistiveness to care and noncompliance with the non‑smoking policy had a comprehensive care plan that was not updated to reflect multiple interventions implemented in response to repeated smoking and vaping violations. Although the care plan noted the need for supervision while smoking and review of the smoking policy, it did not include measures such as daily room searches for smoking materials, added smoke detection in the room, relocation closer to the nurses’ station, q2h visual rounds for smoke, post‑outing nursing checks, initiation of a PAR process for vaping, or issuance of a discharge notice. Facility forms showed inconsistent documentation of daily room searches and incomplete IDT documentation on the PAR tracking, despite multiple documented episodes of policy violations and removal of vaping devices.
A cognitively intact but physically impaired resident with a history of noncompliance with the facility’s non‑smoking policy repeatedly smoked and vaped in his room while keeping multiple vape devices and other items at bedside. The facility’s Smoking Policy required that non‑compliant smokers have daily documented searches and be prohibited from keeping smoking materials in their rooms, yet monitoring forms showed many days without documented searches, Patient at Risk tracking was incomplete, and staff acknowledged that daily room checks and frequent rounds were not consistently performed. Multiple staff, including a CNA, social worker, Infection Preventionist, MDS coordinator, Activities Director, and the Administrator, reported ongoing violations and repeated discovery of vape devices in the resident’s room, including during surveyor observations, demonstrating that the environment was not maintained free from accident hazards and that required supervision and monitoring were not reliably implemented.
Surveyors found that a treatment cart containing topical medications was left unlocked and unattended in a hall across from a resident’s room after wound care was completed by an LPN. The facility’s policy requires that medication carts and supplies be locked or attended and accessible only to licensed or otherwise authorized staff. During interviews, the LPN confirmed the cart had been left unlocked and unattended, the IP LPN confirmed the LPN’s report that the cart was left unlocked, and the Administrator stated that all medications, including topical medications, were expected to be locked when not in sight of authorized staff.
The facility failed to implement its infection prevention and control program by not operationalizing a documented Legionella water management plan despite having a written policy, and by not fully implementing Enhanced Barrier Precautions (EBP) for residents with indwelling devices and other risks. A resident with an indwelling urinary catheter had no EBP care plan or orders, no EBP signage, and staff providing catheter care wore only gloves without gowns, while multiple staff members reported not knowing what EBP was or misidentified who should be on EBP. Another resident receiving tube feeding had care initiated by an LPN who wore gloves but no gown and repeatedly touched her hair with the same gloved hands before handling the feeding tube and equipment, later acknowledging she should have changed gloves and was unaware of EBP requirements, even though other clinical staff stated gowns and gloves should be used for feeding tube care. A resident on isolation for C. diff had a door sign indicating isolation but no instructions for visitors on required PPE or to seek staff guidance, and the IP confirmed there was no system to direct visitors about precautions, contributing to the overall infection control deficiency.
Failure to Maintain Separation of Clean and Soiled Laundry
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to separation of clean and soiled linens. Facility policies titled “Infection Prevention and Control Program” and “Handling Soiled Linens” required that clean linen always be separated from soiled linen. During an observation of the laundry area, all washer and dryer doors were open in the clean linen area. Clean linens, including sheets, towels, blankets, and washcloths, were folded on a table to the left of the washer and dryer room. On the right side of the room, next to the dryers and directly in front of the open door to the dirty laundry room, there were residents’ clean clothes on a rack, piles of folded clean clothes to be hung, a rack of unlabeled clothes, and a bag of unlabeled clothes. Dirty laundry barrels had to be pushed past the clean clothing on the racks to reach the washers, placing soiled items in close proximity to clean items despite policy requirements for separation. Environmental staff working in the laundry stated they believed they were reducing the spread of infection by keeping all doors open, covering dirty barrels, and circulating air, and they explained that the uncovered rack and bagged clothes near the dirty area were no-name clothes sometimes distributed to residents in need. They also stated that the rack of clean personal resident clothing parked in front of the open dirty linen room door was awaiting distribution by a staff member who worked only at night. The Environmental Services Director reported that the door to the dirty side of the laundry should always be closed and that no linen should be on top of dirty barrels. The Infection Preventionist nurse, when shown pictures and concerns about cross-contamination, confirmed there was a problem in the laundry but stated she had not been aware of it previously. The Administrator stated that residents’ clothes should not be stored where they were observed and should be handed out immediately once clean, and that she expected the laundry to be organized to prevent cross-contamination between dirty and clean clothes.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff followed its Enhanced Barrier Precautions (EBP) policy for the use of personal protective equipment (PPE) during high-contact care. The facility’s EBP policy, updated February 2025, requires gowns and gloves for residents with wounds and/or indwelling medical devices, including urinary catheters and ostomies, when staff perform high-contact activities such as bathing, dressing, toileting, hygiene, and catheter care. The policy also directs that gowns and gloves be made available near or outside the resident’s room and that EBP be implemented for residents with indwelling devices or wounds, even if they are not known to be infected or colonized with a multidrug-resistant organism. The resident involved had a suprapubic catheter, colostomy, sacral wound, and neurogenic bladder and bowel, and was care planned for EBP implementation during catheter and skin care. The resident was cognitively intact but dependent on staff for bathing, dressing, toileting, hygiene, bed mobility, and transfers, and used an indwelling catheter and ostomy. During an observation, a CNA provided suprapubic catheter care and a bed bath to this resident while only wearing gloves, despite EBP signage and a star posted on the door and PPE supplies available outside the room. The CNA did not don a gown and was unable to identify any additional actions needed before care until prompted about the EBP signage, at which point he acknowledged he should have worn a gown but forgot. In a subsequent interview, the IP nurse and DON confirmed that staff had been educated that gowns are required during high-contact care for residents with catheters, colostomies, and other devices, and that the posted signage and star were intended to alert staff to the need for enhanced PPE use.
Failure to Assess and Obtain Orders for Self-Administration and Bedside Medication Storage
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policies for self-administration of medications and bedside medication storage for one resident. The facility’s policies require that residents who wish to self-administer medications must be assessed by the interdisciplinary team for cognitive, physical, and visual ability, and that a prescriber’s order for self-administration and bedside storage must be present in the medical record and reflected on the MAR and medication label. For the resident in question, who had diagnoses including cerebral infarction, major depressive disorder with psychotic symptoms, PTSD, hemiplegia and hemiparesis, speech and language deficits, and cerebral atherosclerosis, the EHR showed no assessment for self-administration and no physician order for self-administration or bedside storage, despite active ophthalmic medication orders. The resident’s MDS documented intact cognition with a BIMS score of 15, use of corrective lenses, and functional limitations in range of motion on one side of both upper and lower extremities. Surveyor observations on two consecutive days found an open box of lubricant eye drops on the resident’s bedside table. Staff interviews revealed inconsistent understanding and enforcement of the facility’s policies. A CNA stated that residents did not self-administer medications and that only nurses administered them, but also reported that when she previously reported the eye drops, she was told the resident could have them because he was independent. The Infection Preventionist acknowledged the resident had an order for eye drops and believed he obtained them from the VA, and stated he should not have the lubricant eye drops because they were a hazard for other people. The Administrator confirmed that typically a resident with medications at the bedside should be assessed for self-administration and stated the resident should not have eye drops in his room. The report notes that unsecured medications at the bedside had the potential to cause adverse reactions if accessed or ingested by other residents.
Failure to Maintain Safe and Clean Ceiling Surfaces Throughout Facility
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable homelike environment as required by its Maintenance Service policy, which assigns the Maintenance Department responsibility for keeping the building in good repair and free from hazards. Surveyors observed multiple stained and damaged ceiling tiles in several areas of the facility, including near the nurses' station, in a resident bedroom (room [ROOM NUMBER]A), in the glass day room, and in the middle of the east hall. On several occasions, ceiling tiles near the nurses' station were noted to have tannish-brown circular stains of varying sizes, and at one point a white, moldy substance was observed on a ceiling tile in that same area. In room [ROOM NUMBER]A, surveyors observed brown rings roughly 16 inches in diameter on ceiling tiles located directly above a resident’s bed, with the Maintenance Director later confirming that these tiles were stained, bulging, and at risk of falling on the resident. Additional observations in the glass day room identified two stained ceiling tiles above a resident’s chair, each with brown circular stains approximately three inches in diameter. In the east hall, a ceiling tile with a brown circular stain approximately 10 inches in diameter was also documented. The Maintenance Director and the Administrator both acknowledged that the stains and damage were related to roof leaks associated with recent rainfall, and the Administrator confirmed awareness of roof leaks that had previously been repaired and that the brownish stains were due to recent rain.
Failure to Prevent Sexual Abuse of a Cognitively Impaired Resident by Another Resident
Penalty
Summary
The facility failed to protect a dependent, cognitively impaired resident (R113) from sexual abuse by another resident (R12). R113 had severe cognitive impairment with a BIMS score of 5, was on hospice care, and was fully dependent for toileting, bathing, dressing, footwear, and personal hygiene. On the day of the incident, a CNA observed R12 in R113’s room with his right hand inside R113’s pants while she was seated in a geriatric chair. Staff witness statements and nursing progress notes documented that R12 was found in R113’s room with his hand in her pants, and the facility’s investigation substantiated that R12 touched R113 inappropriately. R12 also had severe cognitive impairment with a BIMS score of 4 and multiple psychiatric and dementia-related diagnoses, including vascular dementia with mood disturbance, Alzheimer’s disease, major depressive disorder, obsessive-compulsive personality disorder, unspecified psychosis, and unspecified mood affective disorder. He required extensive physical assistance, used a manual wheelchair, and was fully dependent for toileting, bathing, lower body dressing, and footwear. R12’s care plan, in place since 2017, identified him as having sexually verbally and physically inappropriate behavior, including documented prior incidents in which he inappropriately touched or attempted to touch female residents. His care plan included interventions such as discussing his behavior when reasonable, explaining that it was inappropriate, intervening to protect others, diverting his attention, and removing him from situations as needed, as well as monitoring and recording occurrences of target behaviors such as sexual aggression toward others. Despite this known history of sexually inappropriate behavior toward female residents and the presence of care plan interventions, R12 was able to enter R113’s room and place his hand inside her pants. The Administrator confirmed that the CNA reported finding R12 in R113’s room with his hand in her pants while R113 was in her wheelchair, and that the facility’s investigation substantiated the abuse allegation. The facility’s abuse policy stated that it would not condone resident abuse by anyone, including other residents, and defined sexual abuse to include sexual harassment, sexual coercion, or sexual assault. The occurrence of this incident demonstrated that the facility did not effectively prevent sexual abuse of R113 by another resident, despite R12’s documented behavioral history and existing care plan.
Failure to Develop and Implement Complete Care Plans for Antipsychotic Use and Foley Catheter Management
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for identified resident needs, as required by its Comprehensive Care Plan policy. The policy states that care plans must address all needs identified in the comprehensive assessment, including medical, nursing, mental, and psychosocial needs, and must be developed within seven days after completion of the comprehensive MDS assessment. It also requires that all triggered Care Area Assessments (CAAs) and other factors identified by the IDT or resident preferences be incorporated into the plan of care. For one resident, R44, the clinical record showed physician orders for Haloperidol 10 mg by mouth twice daily for schizophrenia, along with orders for behavior monitoring and psychiatric medication side effect monitoring. Despite these orders, the resident’s care plan dated 03/11/2026 did not include any care plan addressing antipsychotic medication use or its indication. The MDS Coordinator stated that all residents receiving antipsychotic treatment should have a comprehensive care plan in place beginning with the date the medication was originally ordered, and upon review of the record confirmed that such a care plan was not present for this resident at the time of the survey. For another resident, R3, the care plan dated 03/13/2026 identified a problem of an indwelling catheter secondary to neurogenic bladder related to prostate cancer, with goals including remaining free from catheter-related trauma. The listed interventions included positioning the catheter bag and tubing below bladder level, monitoring and documenting intake and output per policy, and monitoring for pain, discomfort, and signs and symptoms of UTI. However, the care plan did not address the amount of water in the catheter balloon, use of a leg strap or securement device, or other securement measures. Physician orders specified checking a leg strap every shift and documented that the resident was admitted with an 18F catheter attached to a bedside drainage bag, but observations showed the Foley catheter positioned under the resident’s leg without a leg strap or securement device on two occasions, and a CNA reported being unaware that a leg strap was required. The MDS Coordinator confirmed that these ordered interventions were missing from the care plan.
Failure to Revise Care Plan for Ongoing Smoking Policy Noncompliance
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive care plan to reflect current interventions implemented in response to ongoing noncompliance with the facility’s non‑smoking policy. The facility’s policy requires that the comprehensive care plan be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment, and that it include measurable objectives, timeframes, and alternative interventions as needed, with qualified staff notified when changes are made. The resident’s care plan included a focus on resistiveness to care and noncompliance with smoking, noting that the resident continued to go outside beyond facility property to smoke, and an intervention to review the smoking policy with the resident. Another care plan focus identified the resident as a smoker requiring supervision while smoking, with interventions stating the resident required supervision while smoking and that the charge nurse should be notified if a smoking policy violation was suspected. Despite repeated and ongoing noncompliance with the non‑smoking policy, the care plan was not revised to include additional interventions that were actually implemented. These unreflected interventions included daily room searches for smoking paraphernalia, placement of a smoke detector in the resident’s room, relocation of the resident’s room closer to the nursing station, every‑two‑hour visual rounds to check for smoke, nursing checks upon return from outings, initiation of a Patient at Risk (PAR) process for vaping noncompliance, and issuance of a 30‑day discharge notice for repeated violations of the non‑smoking policy. Documentation on the Smoking Materials Monitoring Form showed initials on selected days only, indicating daily room searches were not consistently completed and documented for the entire month. The PAR Smoking Tracking form documented multiple observations of vaping in the room, repeated room checks, removal of vapor devices, and the resident’s refusal to comply with facility policies, with later weeks lacking IDT signatures and documentation, while the PAR Grid showed multiple prior entries for violating the non‑smoking policy.
Failure to Control Smoking and Vaping Hazards for a Noncompliant Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision for a resident with a known history of noncompliance with the facility’s non‑smoking policy. The facility’s Smoking Policy requires that residents not be allowed to keep cigarettes, cigars, pipes, matches, or lighters in their possession or rooms, and that non‑compliant smokers receive daily searches with documentation, while compliant smokers receive weekly searches. The policy also requires incident reports and review in a “Patients at Risk” process whenever smoking materials are found. Despite these written procedures, the resident’s Smoking Materials Monitoring Form for April showed multiple days without documented searches, indicating that required daily room searches were not consistently completed or recorded. The resident at issue was cognitively intact, with a BIMS score of 15, and had significant physical impairments including hemiplegia and hemiparesis on the left side, use of a manual wheelchair, and other neurologic and psychiatric diagnoses such as cerebral aneurysm, cerebral infarction, major depressive disorder with psychotic symptoms, PTSD, and speech and language deficits. The care plan identified the resident as resistive to care and noncompliant with smoking, noting that he continued to go outside beyond facility property to smoke, and also identified him as a smoker requiring supervision while smoking. Progress notes and Patient at Risk documentation showed a pattern of repeated violations of the non‑smoking policy, including multiple instances of vaping and smoking in his room, with staff repeatedly finding vape devices and other smoking paraphernalia in his possession and in his room. Throughout the period reviewed, staff observations and interviews confirmed ongoing noncompliance with the smoking policy and inconsistent implementation of the facility’s own interventions. Staff documented several occasions when the resident was observed vaping or smoking in his room, including in the presence of a state surveyor, and room searches revealed multiple vape devices hidden under the sheets. Staff interviews indicated that daily room checks were not always performed due to competing demands, that logs of every‑two‑hour rounds were not maintained, and that there was confusion or inconsistency regarding whether the resident could keep items such as air freshener at bedside. The social worker, Infection Preventionist, MDS coordinator, Activities Director, CNA, and Administrator all acknowledged that the resident’s room had to be searched for cigarettes and vaping paraphernalia and that prohibited items were repeatedly found, while documentation showed gaps in the required daily searches and incomplete follow‑through on the Patient at Risk tracking process. These actions and inactions resulted in the environment not being kept free from accident hazards as required by the facility’s policy and regulatory standards. The deficiency is further supported by the facility’s own records showing repeated entries on the Patient at Risk grid for violations of the non‑smoking policy over an extended period, as well as narrative notes describing the resident’s statements that he would continue to vape in his room and would simply obtain new devices if they were confiscated. Despite the known pattern of behavior and the facility’s policy requiring close supervision, daily searches, and thorough documentation for non‑compliant smokers, the monitoring forms and staff interviews demonstrate that these measures were not consistently carried out. The presence of multiple vape devices and cans of air freshener at the bedside during surveyor observations, along with staff acknowledgment that room checks were missed and that logs of frequent rounds were not kept, illustrate the facility’s failure to effectively implement its own safety procedures to prevent accident hazards related to smoking and vaping in the resident’s room.
Unlocked and Unattended Treatment Cart with Topical Medications
Penalty
Summary
Surveyors identified a deficiency related to medication storage when a treatment cart containing topical medications was left unlocked and unattended in a hall. The facility’s policy titled “Medication Storage in the Facility,” effective 10/01/2025, states that the medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff lawfully authorized to administer medications, and that medication rooms, carts, and supplies are to be locked or attended by authorized personnel. During an observation on 04/29/2026 at 9:35 AM, after wound care was provided to resident R3 by the wound care LPN, the treatment cart was observed left in the [NAME] hall across from R3’s room, unlocked and unattended for 30 minutes. In an interview, the wound care LPN confirmed that the treatment cart had been left unlocked and unattended. The Infection Preventionist LPN later confirmed that the wound care nurse told her the cart was left unlocked, and the Administrator stated that her expectation was that all medications, including topical medications, be locked when not in sight of a licensed nurse or authorized person. This deficient practice occurred in a facility with a census of 94 residents and involved the failure to follow the facility’s own policy requiring that medication carts be locked or attended by authorized personnel, resulting in unsecured access to topical medications on the treatment cart.
Failure to Implement Legionella Water Management and Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to provide and implement an infection prevention and control program, including a documented water management plan for Legionella and other waterborne pathogens, and a fully implemented Enhanced Barrier Precautions (EBP) program. The Administrator stated there was no Legionella water program in place, and the Maintenance Supervisor reported he was unaware of the requirement for such a program. This was despite the existence of a written Legionella Water Management Program policy, revised in September 2022, which described the need for an interdisciplinary water management team, detailed water system diagrams, identification of risk areas and situations for Legionella growth, control measures, monitoring systems, and annual review. Interviews confirmed that the expectation was that the facility would be conducting this water program, but it was not being done. The facility also failed to implement EBP for residents with indwelling medical devices and other risk factors, as required by its own policy. One resident with Alzheimer’s disease, urinary obstruction, and emphysema had an indwelling urinary catheter documented in the care plan and physician orders, but the care plan did not address EBP related to the catheter, and there was no order for EBP in the record. During catheter-related care, a CNA wore gloves but did not wear a gown, and there was no EBP signage or PPE setup at the room. Multiple staff members, including CNAs and a housekeeper who regularly worked on the resident’s hallway, reported they did not know what EBP was or incorrectly associated EBP only with residents on Transmission-Based Precautions. The DON acknowledged that an attempt to roll out EBP months earlier had not been completed, and that expected signage and PPE caddies for EBP were not fully in place. Additional infection control lapses were observed during tube feeding care and contact isolation. A resident receiving continuous tube feeding had a care plan and physician’s order for enteral nutrition, and an LPN initiated the feeding while wearing gloves but no gown. During the procedure, the LPN repeatedly touched her hair with the same gloved hands and then handled the feeding tube, pump, and syringe used to inject air and check residuals, only removing gloves and using hand sanitizer at the end. The LPN later acknowledged she should have changed gloves after touching her hair and stated she did not know what EBP was or that a gown was required for feeding tube care, while another LPN and the IP stated that EBP with gown and gloves should be used for feeding tube care and that staff should not touch their hair during care without changing gloves and performing hand hygiene. For a resident with a positive urine culture and a subsequent positive C. difficile culture who was on isolation, the door sign indicated isolation but did not provide instructions for visitors on required precautions or direct them to staff for guidance. The IP confirmed there was no system to direct visitors about PPE use for residents on contact isolation and acknowledged that visitors would not know to wear PPE if it was simply present in or on the door of the room. Overall, the survey findings show that the facility did not operationalize its written Legionella water management policy and did not consistently apply its EBP policy for residents with indwelling devices or wounds. Staff interviews and observations demonstrated a lack of knowledge and implementation of EBP, incomplete use of PPE during high-contact care activities such as catheter care and tube feeding, and unclear isolation signage that did not instruct visitors on appropriate precautions. These combined inactions and omissions in policy implementation, staff education, and practice led to the cited infection prevention and control deficiency.
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