Altamaha Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Jesup, Georgia.
- Location
- 1311 West Cherry Street, Jesup, Georgia 31545
- CMS Provider Number
- 115577
- Inspections on file
- 19
- Latest survey
- August 19, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Altamaha Healthcare Center during CMS and state inspections, most recent first.
Surveyors found that an area was not free from accident hazards and lacked adequate supervision to prevent accidents. The environment did not meet safety standards, and insufficient oversight was observed.
The facility failed to maintain food safety and sanitation standards, risking food-borne illness for 52 residents. Observations showed improper food storage, expired items not disposed of, and bare-hand contact with ready-to-eat food. Moldy strawberries were found, and staff lacked awareness of proper food handling procedures.
The facility failed to follow infection control protocols, including proper cleaning of a glucometer between residents and maintaining TB testing records for staff. A nurse used a glucometer without cleaning it per manufacturer's instructions, and six staff files lacked required TB test documentation. Additionally, the facility did not maintain a current infection surveillance program for 2024.
The facility failed to provide written information about the right to formulate an advance directive to five residents or their representatives. Despite the facility's policy requiring this information to be given upon admission or readmission, documentation was missing for these residents, including those with varying levels of cognitive impairment. The Social Services Director confirmed the lack of documentation, indicating a systemic issue in the facility's process.
The facility did not follow its policy to conduct background and criminal checks for four staff members, including CNAs, an LPN, and a DA. The Administrator could not provide the necessary documentation, attributing the lapse to the absence of a Human Resource Director responsible for managing this information.
The facility failed to provide written transfer notices to residents and their representatives during emergent hospital transfers, as required by policy. This affected several residents with various medical conditions, including severe cognitive impairments. Staff interviews revealed uncertainty about responsibility for issuing these notices, and the Administrator confirmed that transfer notices had not been sent to the Ombudsman since taking over the role.
The facility failed to provide written bed hold notices to several residents or their representatives during hospital transfers, as required by policy. This deficiency was identified through record reviews and staff interviews, revealing a lack of clarity about responsibility for issuing these notices. Residents with various medical conditions, including severe cognitive impairments, were affected by this oversight.
A facility failed to update a resident's care plan to include fall interventions such as a low bed, geri chair, and fall mats, despite the resident's moderately impaired cognition and recent falls. Additionally, required care plan conferences were not documented since the resident's admission, as confirmed by staff interviews.
The facility failed to document proper assessments and alternatives for bed rail use for three residents. One resident was observed with assist bars despite no documented failed alternatives, while another had no recent bed rail assessment. The administrator confirmed the lack of documentation, increasing potential risks associated with bed rail use.
A resident in the facility did not receive several prescribed medications due to delays in pharmacy delivery and lack of follow-up documentation. The medications, including Atorvastatin, Ondansetron, Carvedilol, Metformin, Eliquis, and Levothyroxine, were not administered as ordered, and there was no documentation explaining the missed doses. Staff interviews revealed issues with pharmacy delivery times and procedures for handling unavailable medications.
Facility nurses failed to document behaviors and nonpharmacological interventions before administering Seroquel IM to a resident with moderately impaired cognition. The resident's EMR showed orders for Haldol IM for agitation, but the MAR lacked documentation of behaviors or interventions prior to medication administration. The Regional Operations Manager confirmed the absence of documentation, indicating non-compliance with the facility's behavior management policy.
A significant medication error occurred when a resident with diabetes did not receive insulin as ordered due to its unavailability. A registered nurse attempted to administer insulin but found it belonged to another resident. The resident missed multiple insulin doses, and the facility's policy for medication administration was not followed. The Medical Director stated that he could have arranged for the insulin from a local pharmacy if notified of the delay.
The facility failed to post daily nurse staffing information accurately for three out of four survey days, affecting the transparency of available nursing staff for 52 residents. Observations revealed missing postings, and the Administrator confirmed the oversight.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to accidents occurring. Specific actions or inactions leading to this deficiency include the presence of accident hazards and insufficient supervision in the area, as directly observed by surveyors.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, which could potentially lead to food-borne illness among the 52 residents receiving meals from the facility kitchen. Observations revealed that food was improperly stored, with sixteen boxes of canned foods and perishables found resting directly on the pantry floor. Additionally, expired foods were not disposed of in a timely manner, as evidenced by opened cartons of thickened juices and turkey lunch meat being kept beyond their acceptable use-by dates. Interviews with kitchen staff indicated a lack of awareness regarding the proper disposal timelines for these items. Further deficiencies were noted during meal service, where a cook was observed handling dinner rolls with bare hands, touching various surfaces without washing hands in between. Moldy food was also found in storage, with a 16oz. carton of strawberries discovered in a refrigerated reach-in. A dietary aide confirmed that staff did not consistently check produce upon arrival to ensure it was still edible. These actions and inactions demonstrate a failure to maintain proper food safety and sanitation practices as outlined in the facility's Nutrition Services Manual.
Infection Control and TB Testing Deficiencies
Penalty
Summary
The facility failed to adhere to infection prevention and control protocols, specifically in the cleaning and disinfecting of a glucometer between residents' use. During an observation, a registered nurse used a glucometer on a resident without cleaning it according to the manufacturer's instructions, which required the use of Medline Micro-Kill Bleach Germicidal Bleach Wipes. Instead, the nurse used an alcohol wipe after being prompted and admitted to not receiving any formal training on the proper cleaning procedure. The facility's policy required the glucometer to be cleaned and disinfected between each patient, but there was no evidence of training provided to the staff, including the nurse involved in the incident. The facility also failed to comply with pre-employment and annual tuberculosis (TB) testing guidelines. Six out of nine personnel files reviewed lacked documentation of the required two-step TB test at the time of employment, and two personnel files did not have the annual TB test documentation. The administrator confirmed the absence of this information and attributed it to the lack of a Human Resource Director, who was responsible for maintaining these records. This oversight in maintaining proper health records for staff could potentially compromise the safety and health of both staff and residents. Additionally, the facility did not maintain a current infection surveillance program for 2024. The Director of Nursing was unable to provide documentation of infection tracking and trending for the year, as the previous records were not organized or available. The new Director of Nursing, who had been in the position for a short time, was in the process of establishing a new program but had not yet implemented it. The administrator acknowledged the expectation of having an infection surveillance program in place, but no documentation from 2024 was available to demonstrate compliance.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to provide written information regarding the right to formulate an advance directive to five residents or their representatives. This deficiency was identified through a review of records, interviews, and policy review. The facility's policy, dated 08/09/22, mandates that the Social Service Director must inform and educate residents or their Power of Attorney in writing about the right to an advance directive upon admission or readmission. However, documentation was missing for five residents, indicating that they were not provided with the necessary information. Resident 48, with moderate cognitive impairment, and Resident 18, with intact cognition, were not documented as having received this information. Similarly, Resident 12, who had severe cognitive impairment, and Resident 24, had no documentation of receiving advance directive information. Resident 4, who was cognitively intact, confirmed that they had not received this information until recently, despite being in the facility since 2016. The Social Services Director confirmed the lack of documentation for these residents, highlighting a systemic issue in the facility's process for informing residents about their rights to formulate an advance directive.
Failure to Conduct Background Checks for Staff
Penalty
Summary
The facility failed to adhere to its policy of conducting background and criminal checks at the time of employment for four out of nine employee files reviewed. This deficiency involved two Certified Nurse Aides (CNAs), one Licensed Practical Nurse (LPN), and one Dietary Aide (DA). The facility's policy, dated December 21, 2023, mandates that background checks, including criminal history and fingerprinting, be conducted upon submission of an employment application. However, the Administrator was unable to provide the required background and criminal check information for these employees, citing the absence of a Human Resource Director responsible for uploading this information into the computer system.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide written transfer or discharge notices to seven residents and their representatives, as required by policy, during emergent hospital transfers. The policy titled 'Discharge Plan/Transfers' did not address the need for a written notice of transfer, its required contents, or the provision of the notice to the resident and their representative. This oversight was identified through a review of the facility's records, which showed no evidence of written transfer notices for the residents involved. Resident 27, who had multiple medical diagnoses including end-stage renal disease and Alzheimer's dementia, was transferred to the hospital without a written notice. Similarly, Resident 29, with conditions such as congestive heart failure and chronic respiratory failure, was admitted to the hospital from dialysis without receiving a written transfer notice. Interviews with staff, including the Director of Nursing and a Licensed Practical Nurse, revealed uncertainty about who was responsible for issuing these notices. Additional residents, including those with severe cognitive impairments, were also transferred without the required documentation. For instance, Resident 116 was sent to a behavioral hospital due to behavioral issues, and Resident 44, with a BIMS score indicating severe cognitive impairment, was transferred following a change in condition. The facility's Administrator acknowledged the lack of documentation and stated that since taking over the role, transfer notices had not been sent to the Ombudsman, further highlighting the systemic nature of the issue.
Failure to Provide Bed Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to provide a written bed hold notice to seven residents or their representatives during hospital transfers or therapeutic leaves. This deficiency was identified through a review of records, interviews, and facility policy. The facility's policy mandates that residents or their responsible parties receive written information about the bed hold policy at admission and before any transfer. However, the facility did not adhere to this policy for the residents reviewed. Resident 27, who has multiple medical diagnoses including end-stage renal disease and Alzheimer's dementia, was transferred to the hospital without receiving a written bed hold notice. Similarly, Resident 29, with conditions such as congestive heart failure and chronic respiratory failure, was also transferred without the required documentation. Interviews with staff, including the Director of Nursing, revealed a lack of clarity about who was responsible for providing the bed hold notice, indicating a systemic issue in the facility's process. Other residents, including those with severe cognitive impairments, were also transferred without receiving the necessary written notices. For instance, Resident 116, with a BIMS score indicating severe cognitive impairment, was sent to a behavioral hospital without documentation of a bed hold notice. Interviews with the Social Service Director and the Administrator confirmed that there was no documentation of the bed hold policy being provided to residents or their representatives, highlighting a consistent failure across multiple cases.
Failure to Revise Care Plan and Conduct Conferences
Penalty
Summary
The facility failed to revise the care plan for a resident to include necessary fall interventions and did not conduct care plan conferences as required. The resident, who had a moderately impaired cognitive status, was observed in various settings, including a geri chair and with a fall mat next to the bed, but these interventions were not documented in the care plan. The resident had returned from the hospital and experienced falls, yet the care plan was not updated to reflect the use of a low bed, geri chair, or fall mats. Additionally, there was no evidence of care plan conferences being held since the resident's admission, despite the facility's policy requiring such conferences after the completion of the Minimum Data Set (MDS) and during quarterly reviews. Interviews with staff, including the MDS Coordinator, confirmed the absence of documentation for care plan conferences and the lack of updates to the care plan to include the necessary interventions for fall prevention.
Failure to Document Bed Rail Assessments and Alternatives
Penalty
Summary
The facility failed to ensure proper assessment and documentation for the use of bed rails for three residents. Resident 5 was observed with bilateral assist bars in the up position on multiple occasions, yet their electronic medical record (EMR) showed no documented failed alternatives to bed rails. The assessments conducted did not justify the use of side rails as an enabler to promote independence. Similarly, Resident 38 was observed with bilateral assist bars, despite stating they did not use them. The EMR for Resident 38 also lacked documentation of failed alternatives, and no documentation was provided upon request. The facility's administrator confirmed that alternatives should have been documented prior to bed rail use. Resident 3 was found with half side rails on both sides of their bed, but their EMR lacked a recent bed rail assessment. The last assessment was incomplete, and the previous one indicated the family's request for side rails. The administrator acknowledged the absence of recent assessments and confirmed the incomplete status of the last assessment. These deficiencies in documentation and assessment increased the potential risks associated with bed rail use, including injury, entrapment, and death.
Medication Administration Deficiency Due to Pharmacy Delays
Penalty
Summary
The facility failed to ensure timely provision of medications from the pharmacy, resulting in a deficiency in medication administration for a resident. The resident, who was admitted with diagnoses including atherosclerotic heart disease and diabetes mellitus, did not receive several prescribed medications as ordered by the physician. These medications included Atorvastatin, Ondansetron, Carvedilol, Metformin, Eliquis, and Levothyroxine, which were not administered on multiple occasions as documented in the Medication Administration Record (MAR). There was no follow-up documentation to indicate why these medications were not administered. Interviews with facility staff revealed that the medication orders were automatically sent to the pharmacy upon a resident's admission, and the pharmacy delivered medications twice a day. However, it was noted that if a resident was admitted in the afternoon or later, medications might not be delivered until the following morning. The Licensed Practical Nurse (LPN) and the Director of Nursing (DON) confirmed that if a medication was unavailable, it should be sourced from the emergency kit, and a progress note should be documented in the electronic medical record (EMR) to explain the unavailability. Despite these procedures, there was no documentation in the EMR to account for the missed doses. The Director of Nursing acknowledged that pharmacy deliveries had been problematic, with instances of medications not arriving as scheduled. The Medical Director stated that in cases where medications were not available upon admission, the nursing staff should have arranged for the medication to be held until it arrived or sourced it from a local pharmacy. The lack of timely medication delivery and absence of documentation for missed doses contributed to the deficiency identified by the surveyors.
Failure to Document Behaviors and Interventions Before Antipsychotic Administration
Penalty
Summary
The facility nurses failed to document the behaviors and nonpharmacological interventions attempted prior to administering antipsychotic medication, Seroquel IM, to a resident. This oversight was identified during a review of the facility's policy on behavior management, which mandates that targeted behaviors be identified and monitored, and appropriate nonpharmacological interventions be implemented before administering psychoactive medication. The resident in question, who had a moderately impaired cognition with a BIMS score of 12 out of 15, was admitted to the facility and had returned from the hospital. The resident's EMR indicated orders for Haldol IM as needed for agitation, but the MAR did not document any behaviors or interventions prior to the administration of the medication. The Regional Operations Manager confirmed during an interview that there was no documentation of behaviors or nonpharmacological interventions in the resident's records. The absence of documentation suggests that these steps were not completed, which could lead to the resident receiving unnecessary medication. The facility's failure to adhere to its policy on behavior management and documentation was evident in this case, as the necessary steps to justify the use of antipsychotic medication were not recorded.
Significant Medication Error Due to Insulin Unavailability
Penalty
Summary
The facility nurse failed to follow the physician's order and provide a resident with insulin according to the sliding scale order, resulting in a significant medication error. The resident, who was diagnosed with diabetes mellitus and had moderately impaired cognition, did not have the insulin available for administration. During an observation, a registered nurse (RN) attempted to administer six units of Humulin R insulin to the resident based on the Medication Administration Record (MAR), but discovered that the insulin belonged to another resident. The RN reported the unavailability of the correct insulin to the Regional Operations Manager and ordered the insulin, but the resident did not receive the insulin as ordered. The resident missed insulin doses at multiple designated times, and the facility's July MAR indicated that the resident routinely received sliding scale Humulin R insulin prior to the incident. The facility's policy required staff to compare the MAR with the medication label multiple times before administration, which was not followed in this case. The Medical Director stated that the facility should have contacted him if there was a delay in receiving the insulin, as he could have arranged for the medication to be obtained from a local pharmacy. Additionally, the nurses were expected to perform Accu-Chek tests to monitor the resident's glucose levels and notify the Medical Director of any elevated levels.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the daily nurse staffing information was posted to accurately reflect the actual staff hours available to care for the 52 current residents. This deficiency was observed on three out of four survey days. Specifically, observations on 07/28/24 at 6:43 PM, 07/29/24 at 9:30 AM and 10:40 AM, and 07/30/24 at 6:05 PM revealed that the daily nurse staffing was not posted. During an interview on 07/31/24 at 8:15 AM, the Administrator confirmed that the staffing information should have been posted in the glass display window near the front of the facility each day, but it was not posted for three of the four survey days.
Latest citations in Georgia
The facility failed to follow its abuse investigation policy when responding to an allegation that a male resident wandered into a female shared room, allegedly sat on a resident’s bed, inappropriately touched her leg, stared at another resident, and opened the bathroom door to watch a third resident brushing her teeth. The allegation was reported by a cognitively intact resident and involved residents with varying levels of cognitive impairment. The investigation, conducted by the Administrator and former DON, relied only on interviews with a RN and a CNA, did not obtain required written, signed, and dated witness statements, and did not include interviews with other residents to assess their sense of safety. Despite these omissions and incomplete documentation, the facility’s final report concluded the allegation was unsubstantiated.
A resident with protein calorie malnutrition and a terminal prognosis was admitted on hospice with corresponding physician orders and a care plan, but hospice services were not coded on either the admission or quarterly MDS assessments. The MDS Coordinator and two MDS LPNs confirmed that, despite the resident receiving hospice care, Section O of both MDS assessments incorrectly indicated the resident was not on hospice, which the Administrator and DON acknowledged resulted in inaccurate MDS data.
Surveyors found that PTAC unit filters in two resident rooms on one hallway were not maintained free of visible grey, fuzzy debris, despite facility policy requiring regular inspection and cleaning or replacement at least every three months. Across multiple observations on different days, the condition of the dirty filters remained unchanged. The Maintenance Director reported he is responsible for monthly cleaning and checks, including spot checks and inspections in construction areas, and did not dispute the observed dust accumulation when shown. The Administrator confirmed that maintenance staff are responsible for monthly PTAC filter cleaning as part of preventative maintenance and acknowledged that this issue could negatively affect residents’ health and well-being.
A resident with intact cognition and known skin integrity risks reported being left on a bedpan for an extended period and not being adequately cleaned by a CNA. The following shift, another CNA found the resident on soiled linens with a blister on the left upper thigh but did not report this new skin issue to the charge nurse or DON. Subsequent documentation showed development of an open area on the thigh associated with pain, and later NP evaluation identified a larger wound requiring sharp excisional debridement. These events show failure to provide adequate incontinent care and to promptly assess and report a new wound, contrary to the facility’s abuse/neglect prevention policy and CNA responsibilities.
A cognitively intact resident with skin-related diagnoses reported delayed and inadequate incontinent care after using a bedpan, describing prolonged waits for staff response and feeling not properly cleaned by a CNA. The next morning, another CNA found feces-soiled linen and a blister on the resident’s left upper thigh, later documented as a new open area. The resident texted the Administrator stating that a CNA had left feces on her and that she had developed a painful blister, but the Administrator did not report this allegation of neglect to the State Survey Agency as required by facility policy.
A resident with lymphedema and identified risk for pressure ulcers developed a new open wound on the upper thigh, documented by a NP with specific wound measurements. Although the existing care plan included interventions to observe and document skin changes, the care plan was not updated to include this new wound. The Wound Care Nurse and the resident confirmed the wound location, while the MDS Coordinator reported not receiving recent weekly wound reports and only recently learning of the wound. The MDS Coordinator confirmed that the care plan had not been revised in real time as required by facility procedures, resulting in a failure to implement care plan interventions for the newly developed pressure ulcer.
The facility did not complete a required Georgia Criminal History Check System (GCHEXS) fingerprint background check for a CNA, as identified during review of ten employee files with a census of eighty residents. The facility’s abuse-prevention policy required criminal background checks for all employment candidates, but there was no documentation of a fingerprint records check for this CNA. The HR manager, who is responsible for background and fingerprint checks and maintaining employee files, confirmed that the GCHEXS fingerprint check had not been conducted, resulting in a deficiency under F-Tag 600.
Surveyors found that four of six resident shower rooms were not kept free of hazards or adequately cleaned. On one floor, razors were on the floor, dirty gloves and a comb were on a shower bed, floors were stained, an opened gallon of bath soap and a bottle of chemical-resistant spray were present, and a razor and hair clippers were in a bag on the floor along with a shower cap and toothbrush. On other floors, surveyors observed multiple opened containers of skin and hair cleaner, conditioner, and skin ointment, along with a strong urine odor. Unit managers and the Environmental Senior Director stated that CNAs were responsible for cleaning after each resident and that environmental services cleaned shower rooms daily, and acknowledged that items should not be left on the floor and that product containers should be closed.
Surveyors found that staff did not follow standard and transmission-based precautions when handling ice on two floors. On one floor, the ice scoop cover on top of the ice machine had visible black specks near the end of the scoop used to dispense ice. On another floor, the ice scoop was observed submerged in ice and water inside the cooler used to serve residents, despite the unit manager acknowledging that the scoop should not be left in the cooler. The Maintenance Director reported that maintenance cleaned and checked ice machines regularly, while nursing staff were responsible for cleaning scoops and covers. The SDC/Infection Control nurse stated that all staff had been in-serviced on hand hygiene and ice scoop protocol, including that scoops should be stored in a holder after use and never left in the ice.
A resident with multiple serious conditions, moderate cognitive impairment, and total dependence for ADLs was placed in bed with side rails intended to assist with positioning, despite the MDS indicating no bed rail use. Facility records showed no evidence of safe rail spacing or regular inspection of the bed and rails. The assigned CNA, who came on duty late in the evening, last saw the resident around the start of the shift and did not check on him again for several hours, relying on the resident to use a call light. In the early morning, the CNA and an RN found the resident partially out of bed, entrapped in the half side rail, requiring multiple staff to free and reposition him. The resident was unresponsive except for moaning, with altered mental status and respiratory failure documented by EMS and the ER, and later expired at the hospital. The facility’s failure to provide required monitoring and to ensure safe side rail use resulted in neglect and Immediate Jeopardy.
Failure to Thoroughly Investigate Allegation of Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough investigation of an allegation of sexual abuse in accordance with its policy titled “Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating.” The policy required that all allegations be thoroughly investigated, including reviewing documentation and evidence, interviewing any witnesses, interviewing staff on all shifts who had contact with the resident, and completely documenting the investigation, with written, signed, and dated witness statements. A facility-reported incident documented that a male resident was wandering into a female three-bed room, allegedly inappropriately touching one resident, staring at another for a length of time, and then opening the bathroom door and staring at a third female resident while she was brushing her teeth. The allegation was initially reported by a cognitively intact resident (BIMS score 15) and involved another resident with moderate cognitive impairment (BIMS score 8) and a resident with severe cognitive impairment (BIMS score 99). The Administrator reported that the investigation of this incident was conducted by the former DON and herself after the allegation was reported by a RN. She stated that this was not the first time the alleged male resident had wandered into other residents’ rooms and described the allegation as the male resident entering a resident’s room, sitting on the resident’s bed, and allegedly touching the resident’s leg. Staff interviews for the investigation were limited to the RN and a CNA, and the Administrator acknowledged that no written witness statements were obtained, contrary to facility policy. She also confirmed that no additional residents were interviewed to assess their sense of safety following the incident. The facility’s final investigation report concluded that the allegation was unsubstantiated, despite the lack of comprehensive interviews, written statements, and full documentation required by the facility’s abuse investigation policy.
Failure to Accurately Code Hospice Services on MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate completion of the Minimum Data Set (MDS) for a resident receiving hospice services. The facility’s policy on Certification of Accuracy of the MDS requires that appropriate health professionals correctly document residents’ medical, functional, and psychosocial problems using the Resident Assessment Instrument. The resident in question was admitted with diagnoses including protein calorie malnutrition and had a care plan dated 01/09/2026 indicating a terminal prognosis and admission to hospice, with a goal to honor advance directives and provide comfort with dignity. Physician’s orders dated 12/09/2025 also included an order to admit the resident to hospice. Despite this, review of the admission MDS and a subsequent quarterly MDS showed that hospice services were not coded in Section O (Special Treatments, Procedures and Programs), even though both assessments documented a Brief Interview for Mental Status (BIMS) score of five, indicating severely impaired cognition. Interviews with the MDS Coordinator and two MDS LPNs confirmed that the resident had been on hospice since admission and that both the admission and quarterly MDS assessments were incorrectly coded as not on hospice. The MDS Coordinator acknowledged that the MDS should present an accurate clinical picture for a given period and stated that this was a clerical error, resulting in CMS not receiving correct hospice coding for the resident. The Administrator and DON stated their expectation that MDS assessments accurately reflect residents’ services and confirmed that failure to code hospice in the MDS results in an inaccurate reflection of the data.
Failure to Maintain Clean PTAC Unit Filters in Resident Rooms
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to maintain Packaged Terminal Air Conditioner (PTAC) unit filters in a safe, clean condition in two resident rooms on the Sapphire Hallway. The facility’s written policy titled "Instructions" requires that air filters be removed and inspected for cleanliness, washed or replaced if dirty, and at a minimum replaced or thoroughly cleaned every three months. During multiple observations in one room on 3/22/2026, 3/24/2026, and 3/25/2026, the PTAC unit filter was noted to have visible grey, fuzzy debris accumulation, with no change in condition across all three observations. Similar repeated observations on those same dates in another room showed the PTAC unit filter also contained visible grey, fuzzy debris accumulation that remained unchanged. In an interview, the Maintenance Director stated he is responsible for cleaning and checking the PTAC filters monthly, including conducting monthly checks and random inspections in areas where construction is occurring, and confirmed that the maintenance department is responsible for ensuring filters are clean and functioning properly. He also stated that expectations include spot checks of PTAC units. However, during an observation of one of the affected rooms in his presence, dust accumulation was again observed on the PTAC unit filter, and he did not dispute the finding. In a separate interview, the Administrator stated that the maintenance department is responsible for cleaning PTAC filters, which are supposed to be cleaned monthly, and that her expectation is for preventative maintenance to be completed monthly and as needed, noting that a potential negative outcome is the impact on residents’ health and well-being.
Neglect of Incontinent Care and Delayed Wound Reporting Leading to Thigh Wound
Penalty
Summary
The deficiency involves the facility’s failure to prevent neglect and to assess and provide timely wound and incontinent care to a cognitively intact resident with known skin integrity risks. The resident, who had diagnoses including a disorder of the skin and subcutaneous tissue and lymphedema, was care planned as being at risk for pressure ulcer development and skin integrity issues, with interventions directing staff to observe, document, and report any changes in skin status. On a night shift, the resident reported being left on a bedpan for approximately an hour and a half. When the CNA on that shift (CNA BB) assisted with post-toileting care, the resident told her she did not feel adequately cleaned; CNA BB did not recheck or further clean the resident and left the room. The next morning, the resident reported burning in the left upper thigh and informed another CNA (CNA EE) that she had not been cleaned well. During morning care, CNA EE found the pad under the resident soiled with feces and wet with urine and observed a blister on the resident’s left upper thigh, but did not report the new blister to the charge nurse or DON. A subsequent Skin Wound Note documented a new open area on the left posterior thigh with the resident reporting pain while sitting on the bedpan. Later, an NP wound care consult documented that the thigh wound had been present for approximately two weeks per nursing report and measured 3.5 cm x 4.0 cm x 0.2 cm, requiring sharp excisional debridement to remove necrotic tissue and decrease bacterial burden. On observation by the surveyor with the Wound Care Nurse, the left upper thigh area was open to air, shiny pink and granular, about the size of a half dollar. These findings demonstrate that the facility did not follow its abuse/neglect prevention policy and CNA job responsibilities to provide necessary care and to report changes in condition, resulting in neglect of incontinent care and delayed wound assessment and treatment for this resident.
Failure to Report Allegation of Neglect to State Survey Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of neglect to the State Survey Agency (SSA) as required by its own abuse and neglect reporting policy. The facility’s policy, dated 1/2025, states that any complaint, allegation, observation, or suspicion of resident neglect must be immediately communicated to the Abuse Coordinator and promptly investigated and documented, and that all alleged violations involving mistreatment, abuse, or neglect will be thoroughly investigated under the direction of the Administrator in accordance with state and federal law. Despite this, the Administrator acknowledged that an allegation of neglect reported by a resident was not reported to the SSA. The resident involved was cognitively intact, with a BIMS score of 15, and had diagnoses including a disorder of the skin and subcutaneous tissue and lymphedema. The resident reported that during a night shift she requested assistance for incontinent care after using a bedpan and experienced multiple delays before a CNA assisted her. She stated that when the CNA finally provided care, she did not feel adequately cleaned, and the CNA did not verify cleanliness before leaving. The next morning, another CNA found soiled linen with feces and a blister on the resident’s left upper thigh, which the resident reported as burning. A subsequent skin/wound note documented a new open area on the left posterior thigh. The resident texted the Administrator describing that a CNA had left feces on her and that she had developed a painful blister. The Administrator confirmed receiving this text but did not report the allegation of neglect to the SSA, despite being aware it should have been reported.
Failure to Update and Implement Care Plan for Newly Developed Pressure Ulcer
Penalty
Summary
Surveyors identified a failure to implement and update the care plan for a newly developed pressure ulcer for one resident. The facility’s policy "RAI Care Planning Management" requires a comprehensive, accurate assessment and real-time modification of the care plan when changes occur. The resident was admitted with diagnoses including a disorder of the skin and subcutaneous tissue and lymphedema. A recent MDS quarterly assessment showed the resident was cognitively intact (BIMS 15), at risk for pressure ulcer development, and had no unhealed pressure ulcers at that time. The existing care plan, dated 6/6/2024, identified potential for pressure ulcer development and skin integrity issues related to immobility and lymphedema, with interventions to observe, document, and report changes in skin status, including wound size, stage, and signs of infection. Subsequently, a NP wound report documented a new open wound on the resident’s thigh that had been present for approximately two weeks, with specific measurements recorded. During observation and interview, the Wound Care Nurse and the resident confirmed the wound was on the left upper thigh, which differed from the NP report that referenced the right thigh. The MDS Coordinator reported she previously received weekly wound sheets from the Wound Care Nurse but had not received one in about a month, and that the DON was now responsible for emailing the weekly wound report. She verified that the last wound report she received did not include this resident and stated that new wounds should be discussed in the morning management meeting and the care plan updated in real time. The MDS Coordinator confirmed she only recently became aware of the upper left thigh wound and that the resident’s care plan had not been updated to reflect this new wound, resulting in a failure to implement care plan interventions for the newly developed pressure ulcer.
Failure to Complete Required GCHEXS Fingerprint Check for CNA
Penalty
Summary
The facility failed to ensure that a Georgia Criminal History Check System (GCHEXS) fingerprint check was conducted for one CNA among ten employee files reviewed, despite a census of eighty residents and a written policy requiring criminal background checks for all employment candidates. The policy titled "Freedom of Abuse Abuse Prevention Fast Alert" dated 1/2025 states that, as part of pre-employment screening, all candidates must authorize a criminal background check for conviction of crimes. During record review with the Human Resources Manager (HRM), there was no documentation of a fingerprint records check for CNA BB, and the HRM confirmed that this CNA did not have a GCHEXS fingerprint check conducted. The HRM also stated that she is responsible for background checks, fingerprint checks, reference checks, and maintaining employee files. This failure to complete the required fingerprint background check for CNA BB resulted in noncompliance cited under F-Tag 600. No resident-specific medical histories, conditions, or direct resident care events were described in the report related to this deficiency.
Failure to Maintain Safe and Clean Conditions in Multiple Resident Shower Rooms
Penalty
Summary
Surveyors identified a deficiency related to accident hazards and inadequate environmental controls in multiple resident shower rooms. On the 4th floor, observation with the Unit Manager showed four razors on the floor, dirty gloves and a dirty comb on a shower bed, stained/dirty floors, an opened gallon bottle of complete bath soap, and a bottle of chemical resistant spray in the shower room. A razor and hair clippers were found in a black bag on the floor, and a shower cap and toothbrush were lying on the floor. The 4th floor Unit Manager stated that CNAs were supposed to clean up before showering residents and acknowledged that the items found should not be on the floor. The Environmental Senior Director reported that shower rooms were cleaned daily, with responsibilities including cleaning high-touch areas, sweeping and mopping floors, removing linen, and cleaning the area, and stated there had been no complaints about showers not being cleaned. On the 3rd floor, observation with the Unit Manager revealed an open bottle of skin and hair cleaner, an open bottle of conditioner, and an open bottle of skin ointment in the resident shower room. The 3rd floor Unit Manager stated that items in the shower room should be closed and that CNAs were to clean after each resident. On the 2nd floor, observation with the Unit Manager revealed two opened gallon containers of skin and hair cleaner and a strong urine odor in the shower room. The 2nd floor Unit Manager stated that the soap should have a top on it and that CNAs were responsible for cleaning after each resident. These observations and interviews showed that four of six resident shower rooms were not maintained free of hazards and were not cleaned as expected by facility staff, creating the potential for injury and spread of infection as stated in the report.
Improper Ice Scoop Handling and Storage Breaches Infection Control Protocol
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to improper handling and storage of ice scoops on two of four floors. On the 4th floor, observation of the ice scoop and scoop cover showed black specks near the end of the scoop used to put ice in cups, and the scoop cover was located on top of the ice machine. The 4th floor Unit Manager stated that kitchen staff cleaned the scoops once a week and acknowledged that the scoop should be clean. On the 3rd floor, observation of the ice chest/cooler used to serve residents revealed the ice scoop submerged in ice and water. The 3rd floor Unit Manager later confirmed that the ice scoop was not supposed to be left in the cooler. The Maintenance Director reported that maintenance staff were responsible for cleaning the ice machines, which were checked weekly and monthly, while nursing staff were responsible for cleaning the ice scoops and covers. The Staff Development Coordinator/Infection Control staff stated that all staff had been trained in infection control procedures, including hand hygiene and handling of the ice scoop and holder, and that staff had been educated that the ice scoop should be placed in the scoop holder after use and never left in the ice. Documentation in the maintenance logbook showed monthly checks and cleaning of all four ice machines, and the ice machine cleaning log showed that the ice machines on the 2nd, 3rd, and 4th floors and in the kitchen had been cleaned on specific dates. Staff training records indicated that an in-service on handwashing and ice scoop protocol had been provided for all staff.
Neglect Related to Inadequate Supervision and Unsafe Side Rail Use Leading to Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect related to inadequate supervision and oversight of side rail use, resulting in entrapment. Facility policies on Abuse, Neglect and Exploitation required protections to prevent neglect, defined as failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. The policy on Proper Use of Bed Rails required a person-centered approach, attempts at alternatives before bed rail use, and ensuring correct installation, use, and maintenance of bed rails, including attention to entrapment risk. For this resident, the Medicare 5-day MDS indicated moderate cognitive impairment (BIMS score of 8), total dependence on staff for all ADLs, and documented that bed rails were not used, while an admission assessment documented side rails were placed to assist with movement in bed. Facility records showed no evidence that safe rail spacing and regular inspection of side rails and beds had been completed. The resident had multiple serious medical diagnoses, including acute and subacute infective endocarditis, end stage renal disease, hemiplegia and hemiparesis following cerebral infarction, bacteremia, and cervical disc degeneration, and was dependent on staff for all ADLs. Nursing staff last observed the resident at 12:46 am when a sponge bath was provided; there was no documented monitoring or ADL assistance between 12:46 am and 4:30 am. The assigned CNA reported coming on duty at 11:00 pm, seeing the resident up with the bed in a low position, placing the call light in the resident’s hands, and not seeing or checking the resident again until approximately 4:30–5:00 am, stating that the resident did not press the call light during that time. Around 5:00 am, the CNA requested help from the RN, reporting that the resident needed assistance. The RN found the resident with the lower part of his body hanging off the bed and the upper body still on the bed, with his elbow wedged into the half side rail, requiring three staff to reposition him back into bed. The RN stated the resident, who was quadriplegic, was no longer as alert as when put to bed, did not respond to sternal rubs, had open but unfocused eyes, and was not verbally interactive. The CNA described finding the resident on his knees, all the way out of bed, with one hand tangled in the side rail, and noted that he was moaning but not talking after being returned to bed. Progress notes documented that EMS was called for evaluation and treatment due to the resident’s condition, and hospital ER records indicated he arrived with altered mental status and respiratory failure, agonal respirations, and a GCS of 3. The facility’s Maintenance Director stated bedrails had been checked the prior year but could not provide proof, and requested documentation of safe rail spacing and regular inspection was not provided.
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