Etowah Landing

Based on observation, interviews, record review, and a review of the facility policy titled Cleaning and Disinfection of Resident-Care Items and Equipment, the facility failed to implement infection prevention and control practices for two of five sampled residents (R) (R50 and R23). In addition, the facility failed to ensure proper cleaning, disinfection, and separation of reusable resident care equipment for two of two units. This failure created the potential for cross-contamination and transmission of infection.Findings include: A review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised July 2014, documented Policy Statement: Resident- care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current Centers for Disease Control (CDC) recommendations for disinfection and the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Standard. 1. During an observation on 04/12/2026 at 2:50 PM, R50 was observed in bed, and the bed was in the lowest…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure a clean and homelike environment on two of three units (Meadows Unit and the Springs Unit) related to an unclean room and broken bathroom tissue holder, lack of use of proper bed linen, unclean packaged terminal air condition (PTAC) units, and lingering malodorous odors. The deficient practice had the potential to affect resident comfort and safety.Findings include:During multiple observations on 04/11/2026 and 04/12/2026, the Packaged Terminal Air Conditioners (PTAC) units in the Meadows Dining Room had a thick covering of dust buildup.During an observation on 04/11/2026 at 8:40 AM, the resident in room [ROOM NUMBER]A was observed lying in the bed with a flat sheet not visible on the mattress underneath her upper body. The flat sheet was observed on the bed, bunched up under the resident's lower body, buttocks, and lower extremities. During an observation on 04/11/2026 at 9:52 AM, the resident in room [ROOM NUMBER]C was observed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to ensure that three of seven medication and treatment carts (Springs Medication Cart #1, Springs Medication Cart #2, and Meadows Treatment Cart #1) were locked and secure when not in use. The deficient practice increased the risk of unauthorized access to medications and diversion.Findings include:During entry into the facility on [DATE] at 7:30 AM, the Springs Medication Cart #1 and the Springs Medication Cart #2 were observed unlocked and unattended. Two staff members were observed seated behind the Springs Nursing Station. During an observation on 04/11/2026 at 7:40 AM, during the initial tour of the facility, the Meadows Treatment Cart #1 was observed unlocked and unattended. At that time, Licensed Practical Nurse (LPN) AA confirmed that the treatment cart was left unlocked and unattended. She stated that the wound care nurse must have left it open the day before.A review of the Medication Cart/Storage document (undated) revealed that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff and resident interviews, record review, and review of the facility policy titled Care of Fingernails/Toenails, the facility failed to ensure Activities of Daily Living (ADL) care was provided for two of eight sampled residents (R) (R2 and R9) related to fingernail care. The deficient practice placed R2 and R9 at risk of diminished quality of life.Findings include:1. During an observation on 04/11/2026 at 2:54 PM, and 04/12/2026 at 11:29 AM, R9's fingernails were observed to be long with a heavy accumulation of brown debris under the nail bed. A review of the electronic medical record (EMR) revealed that R9 was admitted to the facility on [DATE], with diagnoses included, but not limited to unspecified dementia, anxiety and depression.The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R9 was dependent on staff for the ability to maintain personal hygiene and maximum assistance with showering/bathing. A review of the care plan revised 02/26/2026, documented R9…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and review of the facility policy titled Restorative Nursing Policy and Procedure, the facility failed to ensure that one of two sampled residents (R) (R2) received restorative services to prevent contractures and/or to prevent a decrease in range of motion (ROM) mobility. The deficient practice increased the risk that R2 would experience worsening contractures.Findings include: During an observation on 04/11/2026 at 10:20 AM, and 3:36 PM, R2 was observed in bed with the left hand visible on top of the blanket. R2's left hand was observed in a contracted, flexed position, with the fingers tightly drawn together. No splints were observed in the room. During an observation on 04/12/2026 at 9:16 AM, the wound care nurse demonstrated R2's lack of ROM in the right hand which was closed and contracted. R2's fingers were bent with the fingernails digging into the palm of her hand. No splints or washcloths were rolled in R2's hands. The wound care nurse confirmed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident and staff interviews, and facility policy review, the facility failed to send a written notification of hospital transfer to the resident and/or resident representative (RR) for three of three residents (Resident (R) 22, R56, and R62) reviewed for hospital transfer of 27 sample residents. This failed practice had the potential to affect the residents and their RR by not having the knowledge of where and why a resident was transferred and/or how to appeal the transfer, if desired. Findings include: Review of the facility's policy titled, Transfer or Discharge Documentation, an initiation date of 2001 and a revision date of 12/16, indicated .details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider . When a resident is transferred or discharged from the facility, the following information will be documented in the medical record .That an appropriate notice was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and facility policy review, the facility failed to ensure one 27 sampled residents (R) (R287) was free from significant medication errors when R287 did not receive diltiazem (Cardizem), a blood pressure medication, as ordered by the physician on 10 days. This failure had the potential to cause adverse reactions of high blood pressure. Findings include: Review of the facility's policy titled, Administering Medications, revised December 2012, revealed Medications must be administered in accordance with the orders . Review of R287's admission Record located in the Profile tab of the electronic medical record (EMR) revealed R287 was admitted to the facility on [DATE] for a 14-day respite stay, with diagnoses including heart disease, dementia, and hypertension. R287 discharged home on [DATE]. Review of R287's Physician Orders located under the Orders tab of the electronic medical record (EMR) and dated 10/1/2024, revealed R287 was to receive diltiazem, 120 milligrams (mg), two…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interviews, and review of the facility's policies, the facility failed to have a hands-free trash receptacle at the hand washing sink, failed to ensure the exhaust hood filters were clean and free from grease build-up, and failed to properly label and date opened food items. These failures had the potential to affect 69 residents receiving an oral diet. Findings include: 1. Observation on 2/9/2024 at 9:45 am during the initial tour of the kitchen with the Dietary Manager (DM), revealed the hand washing sink near the main entrance to the kitchen, adjacent to the dish room, revealed the only trash receptable available to dispose of used paper towels was a large 50-gallon trash can covered with a lid. Continued observation revealed the DM lifting the dirty trash bin lid to dispose of a used paper towel. Interview on 2/9/2024 at 9:45 am, the DM confirmed that the only trash receptacle near the hand washing sink near the main entrance to the kitchen, was a 50-gallon trash can covered with lid, and the lid would need to be touched in order to dispose of used…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interviews, review of the Policies and Procedures for Nursing Facility Services, and review of the policy titled Healthcare Management-Legionella Infection Control, the facility failed to develop and implement a water management plan to include policies and procedures for the prevention and spread of Legionella and other opportunistic pathogens in the building water system. In addition, the facility failed to designate a clean and dirty room on the ventilator unit to reduce the cross contamination of respiratory therapy equipment. The census was 93. Findings include: Review of the document titled Healthcare Management-Legionella Infection Control dated 7/22/2021 revealed Legionella bacteria is found in freshwater environment. The bacteria can become a health concern when it grows in building water systems such as: o Shower heads and sink faucets. o Cooling towers found in centralized air- cooling systems. o Decorative fountains o Hot water tanks and heaters. o Large complex plumbing systems. o Medical equipment such as a C- PAP machine. The facility will…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and review of the policy titled Cleaning and Disinfection of Resident Care Items and Equipment, the facility failed to ensure that it maintained a clean and comfortable home-like environment for two of 30 sampled residents (R) (R54 and R63). Specifically, the facility failed to upkeep the cleanliness of resident wheelchairs related to dirt and hair build up. Findings: Review of the policy titled Cleaning and Disinfection of Resident Care Items and Equipment revised July 2014, revealed the policy is resident care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogen Standard. Observation on 2/10/2024 at 12:15 pm revealed a thick gray buildup and hair on the undercarriage of the wheelchair for R63. Observation on 2/10/2024 at 1:34 pm revealed R54 sitting in her wheelchair near the front nurse's station. There was a thick gray build-up noted to the wheel spokes and undercarriage of the wheelchair. Interview on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews, the facility failed to ensure the environment was free from potential accident hazards by not ensuring that a portable oxygen tank was stored securely in resident (R) 233's room of 43 resident rooms. Findings include: Review of medical record revealed R233 was admitted to the facility on [DATE] with diagnoses that included but was not limited to chronic congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD). Observation on 2/9/2024 at 3:35 pm, in R233's room was a free-standing portable oxygen tank sitting unsecured on the floor, near the wall by the television. Observation on 2/9/2024 at 3:55 pm, Licensed Practical Nurse (LPN) LL exited room of R233. During an observation and interview on 2/9/2024 at 3:59 pm, LPN KK confirmed the oxygen tank in R233's room was unsecured. She acknowledged that the oxygen tank should not have been sitting directly on the floor and then removed the oxygen tank from the room. Interview on 2/9/2024 at 4:00 pm, LPN LL…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and review of the policy titled Antipsychotic Medication Use, the facility failed to ensure that psychotropic medications including antianxiety medications were not ordered as needed (PRN) beyond 14 days unless clinically indicated for two of five residents (R) (R8 and R38) reviewed for unnecessary medications. Findings are: Review of the policy titled Antipsychotic Medication Use revised 12/2016, revealed Policy Interpretation and Implementation: Number 15. as needed (PRN) psychotropics medications would not be utilized beyond 14 days unless the healthcare practitioner provided a documented rationale for the extended order and had evaluated the resident for the appropriateness of that medication. 1. Review of the clinical record revealed R8 was admitted to the facility on [DATE] with diagnoses including fibromyalgia, osteoarthritis, congestive heart failure (CHF), hypertension (HTN), hypothyroidism, and anxiety disorder. Review of the Physician Orders (PO) dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.