Appling Nursing And Rehabilitation Pavilion
Inspection history, citations, penalties and survey trends for this long-term care facility in Baxley, Georgia.
- Location
- 163 East Tollison Street, Baxley, Georgia 31513
- CMS Provider Number
- 115262
- Inspections on file
- 16
- Latest survey
- May 23, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Appling Nursing And Rehabilitation Pavilion during CMS and state inspections, most recent first.
A resident who required assistance with eating and drinking sustained second-degree burns after being served hot tea without the temperature being checked. The CNA provided the beverage from a pantry coffee pot and left the resident unattended, resulting in a spill and injury. Prior to the incident, staff did not routinely check hot beverage temperatures, and there was no policy or guidance posted in the facility. Temperature logs showed inconsistent monitoring, and other staff confirmed that temperature checks were not standard practice.
Staff failed to follow care plan interventions for two residents with severe cognitive impairment, resulting in one resident eloping from the facility twice and another sustaining a femur fracture during an improper transfer. Required supervision, risk assessments, and use of transfer equipment were not consistently implemented, leading to serious harm and Immediate Jeopardy status.
The facility did not provide adequate supervision or follow care plans for two residents with severe cognitive impairment, leading to one resident eloping from the facility twice and another sustaining a femur fracture during an improper transfer. Staff failed to use required equipment and did not consistently follow policies for elopement prevention and safe transfers, resulting in actual harm and placing residents at risk.
A resident eloped from the facility twice due to failures in supervision and door alarm procedures. On both occasions, the resident exited through doors that did not alarm or were not reset, and staff were unaware of the resident's absence. The facility's IDT only addressed the specific resident after the incidents and did not assess other residents for elopement risk. Door checks were inconsistently implemented, occurring only on the day shift, leaving gaps in monitoring and resident safety.
The facility did not maintain an effective infection prevention and control program during an Influenza A outbreak, as the DON was unable to provide accurate case tracking, failed to report the outbreak to health authorities, and demonstrated confusion regarding proper isolation precautions. These deficiencies affected all residents and staff during the outbreak.
A resident with moderate cognitive impairment reported to nursing staff that a CNA was rough, manhandled, and yelled at him during a transfer. Although the incident was reported internally the day after it occurred, the administrator did not notify state and local authorities within the required timeframe, resulting in a delay that did not comply with facility policy for reporting abuse allegations.
A resident with diabetes and other medical conditions experienced multiple blood sugar readings above 400 mg/dL. Despite physician orders to send the resident to the ER and withhold insulin until lab confirmation, staff administered insulin and did not send the resident out, only attempting to contact the physician. No negative outcomes were documented.
The facility did not provide quarterly financial statements to residents or their responsible parties for trust fund accounts, as required by policy. Interviews revealed that residents, despite having little to no cognitive impairment, had not received these statements. The Social Service Director admitted to issuing statements every six months without proof of distribution, and the administrator was unaware of this practice until recently informed.
The facility failed to maintain sanitary conditions, leading to cross-contamination. An LPN used a treatment cart for wound care without sanitizing it between rooms, and improperly handled a foley catheter by placing it on a resident's bed instead of below the bladder. The LPN lacked training in wound care and infection control, contributing to these deficiencies.
A resident with multiple sclerosis and moderate cognitive impairment had stage 4 and stage 2 pressure ulcers, but the facility failed to develop a care plan to address these conditions. The facility's policy requires care plans to be updated and communicated with relevant staff, but this was not done, as confirmed by the Administrator, DON, and ADON.
Resident Burned by Unchecked Hot Beverage Temperature
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral infarction and unspecified dementia, who required set up or clean up assistance with eating or drinking, was served hot tea without the temperature being checked. The Certified Nurse Assistant (CNA) poured hot water from a coffee pot in the hall's pantry and gave it to the resident, then left the room to assist another resident. After approximately eight minutes, the CNA returned and found that the hot tea had spilled on the resident, resulting in burns. The nurse assessed the resident and noted what appeared to be a third-degree burn on the right hip area, and the resident was subsequently sent to the emergency room and then transferred to a burn unit, where a second-degree burn was confirmed and a skin graft was performed. Prior to this incident, the facility did not have a policy regarding the serving temperature of hot beverages, nor were there postings or thermometers available in the pantries for staff to check beverage temperatures. Staff interviews confirmed that it was not standard practice to check the temperature of hot beverages before serving them to residents. The CNA involved in the incident reported that she could not find a thermometer and relied on the absence of steam to judge the temperature, which proved inadequate. Other staff corroborated that temperature checks were not routinely performed before the incident. Observations and record reviews revealed that the facility's temperature logs for hot beverages showed a wide range of serving temperatures, some of which exceeded safe limits. There were also gaps in documentation for certain dates. Additionally, the Activities Director reported serving coffee during activities without checking temperatures. The lack of a clear policy, absence of temperature monitoring, and failure to provide adequate supervision when serving hot beverages directly contributed to the resident sustaining significant burns.
Failure to Implement and Follow Care Plans Results in Elopement and Injury
Penalty
Summary
Facility staff failed to implement and follow care plan interventions for two residents, resulting in significant negative outcomes. One resident with severe cognitive impairment and a history of Alzheimer's disease experienced two elopement incidents, despite a care plan in place since 2021 that required staff supervision when moving on and off the unit. After the second elopement, additional interventions such as keeping the resident in view of staff at all times and daily door checks were documented, but the resident had not received an elopement risk assessment since admission, and some interventions were not consistently added to the care plan after the first incident. Another resident, also with severe cognitive impairment and dependent on staff for transfers, sustained a fracture of the distal left femur. The care plan specified that transfers required two staff members and the use of a mechanical lift. However, staff interviews revealed that the resident was transferred to a shower chair without the required equipment or sufficient staff assistance. Multiple staff members acknowledged that the resident needed two-person assistance and a lift, but these protocols were not followed during the transfer, likely resulting in the injury. The facility's failure to implement and maintain individualized care plans as required led to serious harm and the likelihood of further injury. The deficiencies were identified as causing or having the potential to cause serious injury, harm, impairment, or death, and Immediate Jeopardy was declared by surveyors. The noncompliance was determined to have existed for over a month prior to the survey exit, and the Immediate Jeopardy status remained ongoing at the time of survey exit.
Failure to Prevent Elopement and Ensure Safe Transfers Resulting in Resident Harm
Penalty
Summary
The facility failed to ensure that residents at risk for elopement and those requiring assistance with transfers received adequate supervision and appropriate interventions, resulting in two significant incidents. One resident with severe cognitive impairment and a history of wandering exited the facility without staff knowledge on two separate occasions. The first elopement occurred when the resident left through a door that had not been reset to alarm, and the second incident involved the resident being found outside in a wheelchair. The care plan for this resident included supervision when moving on and off the unit, but there was no evidence that an elopement risk assessment had been completed since admission, nor was the care plan updated after the first elopement. Door lock checks were initiated only after the second incident, and documentation of these checks prior to the second elopement was not available. Another resident, also with severe cognitive impairment and dependent on staff for transfers, sustained a fracture of the distal left femur. The care plan specified the use of a mechanical lift and assistance from two staff members for transfers. However, staff interviews revealed that the resident was transferred from bed to a shower chair and back without the use of a mechanical lift or gait belt, and not always with two staff members present. The facility's investigation could not substantiate the exact cause of the injury but concluded it likely occurred during a transfer due to improper technique and failure to follow the care plan. The Director of Nursing confirmed that the resident requiring two-person transfers was not always assisted according to the care plan and that staff did not consistently use the required equipment. The facility's policies on elopement and safe transfers were not followed, and staff were either unaware of or did not implement the necessary interventions. These failures resulted in actual harm to one resident and placed others at risk for serious injury or death.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Door Alarm Procedures
Penalty
Summary
The facility failed to administer its operations in a manner that ensured effective and efficient use of resources to prevent resident elopement. Specifically, a resident was able to exit the facility without staff knowledge on two separate occasions. On one occasion, the resident was found outside with a small skin tear and was unable to answer questions. Documentation revealed that the resident exited through a door that had not been reset to alarm, and on another occasion, the exit door did not alarm, allowing the resident to leave the building unattended and without staff awareness. Interviews and record reviews indicated that after the first elopement, the facility's Interdisciplinary Team (IDT) met to discuss interventions for the affected resident but did not assess or address the risk of elopement for other residents. Door checks were implemented only on the day shift, leaving other shifts without this safety measure. The Administrator acknowledged that all residents were at risk for elopement and that the facility failed to conduct risk assessments for those at high risk. The lack of comprehensive supervision and processes placed residents at risk for multiple elopements and serious adverse outcomes.
Failure to Maintain Effective Infection Control Program During Influenza Outbreak
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as required by its own policy and regulatory standards. The Director of Nursing (DON), who also served as the Infection Preventionist, was unable to provide an accurate and up-to-date line list of residents and staff affected by an ongoing Influenza A outbreak. Discrepancies were found between the facility's line list and the resident matrix, with several positive cases not included in the official documentation. The DON also reported that staff illness was only tracked by call-out dates or doctor's notes, and that a significant portion of staff had been out with the flu. Additionally, the facility had not reported the outbreak to the appropriate health authorities, despite state requirements to do so. Further, the DON demonstrated a lack of knowledge regarding proper isolation precautions for influenza, incorrectly equating airborne and droplet isolation and applying multiple types of isolation simultaneously. Observations confirmed that residents were placed under contact, airborne, and droplet precautions, which may not align with best practices for influenza. The DON admitted to not knowing that reporting outbreaks to the health department was required and had not done so. These failures affected all 81 residents in the facility during the outbreak.
Failure to Timely Report Alleged Staff-to-Resident Abuse
Penalty
Summary
Facility staff failed to timely report an allegation of staff-to-resident abuse involving a resident with moderate cognitive impairment and multiple medical diagnoses, including heart disease, anxiety disorder, and dementia. The resident reported to a nurse that a male CNA was rough, manhandled him during a transfer, and yelled at him. The incident occurred during a transfer for a scheduled haircut, and the resident expressed pain and requested that the CNA not enter his room again. The resident initially reported the incident to nursing staff the day after it occurred, and the nurse immediately informed the DON, who began collecting witness statements. Despite facility policy requiring that all allegations of abuse be reported to the state agency and other authorities within specified timeframes (immediately, but not later than 2 hours if abuse is involved, or within 24 hours otherwise), the administrator did not report the incident to state and local authorities until two days after the initial report was made to nursing staff. Interviews with the administrator, DON, and involved staff confirmed the delay in reporting, which was not in accordance with the facility's written procedures for abuse, neglect, and exploitation prevention and reporting.
Failure to Follow Physician Orders for Blood Glucose Management
Penalty
Summary
The facility failed to follow physician orders for a resident with diabetes, a history of heart attack, and high blood pressure, who was cognitively intact. The physician's orders specified that if the resident's blood sugar (BS) was over 400 mg/dL two hours after insulin administration, the resident should be sent to the emergency room (ER) and the physician must be notified. Additional orders required repeat finger stick and STAT lab confirmation if BS was less than 40 mg/dL or greater than 400 mg/dL, and to withhold insulin until lab confirmation was received. On two consecutive days, the resident's BS readings were consistently above 400 mg/dL, reaching as high as 505 mg/dL. Despite these elevated readings, the resident was not sent to the ER as ordered, and insulin was administered without waiting for lab confirmation. Documentation showed that staff attempted to contact the physician and faxed information, but the required actions per the physician's orders were not followed. There were no documented negative outcomes for the resident as a result of these actions.
Failure to Provide Quarterly Financial Statements
Penalty
Summary
The facility failed to provide quarterly financial statements to residents and/or their responsible parties for trust fund accounts managed by the facility, affecting all 66 residents with such accounts. The facility's policy requires that individual financial records be made available through quarterly statements and upon request. However, interviews with residents revealed that they had never received these statements, although they could obtain verbal account balances upon request. The residents involved, who had little to no cognitive impairment, confirmed they had not received the required quarterly statements. The Social Service Director (SSD), responsible for managing the resident trust fund accounts, admitted to not having proof that quarterly statements were provided. Instead, she stated that statements were issued every six months, either mailed to families or placed on residents' bedside tables without confirmation of receipt. The SSD also lacked documentation to verify the distribution of these statements. The facility administrator was unaware of this deviation from policy until informed by the SSD, who acknowledged that only one statement had been issued since October 2023, contrary to the quarterly requirement.
Infection Control Deficiency Due to Improper Sanitation Practices
Penalty
Summary
The facility failed to maintain sanitary and clean conditions, leading to cross-contamination across three hallways. Specifically, the treatment cart used for wound care was not cleaned and sanitized after being used in residents' rooms. An LPN was observed rolling the treatment cart into a resident's room, where it came into contact with a foley catheter's dignity bag and other surfaces. The LPN did not sanitize the cart after leaving the room and continued to use it in other rooms without cleaning it. Additionally, the LPN placed a foley catheter on a resident's bed, which is not the correct positioning, as it should be below the bladder level. The LPN also placed a wedge on the floor before using it on the resident. Interviews revealed that the LPN lacked training in wound care and infection control, which contributed to the improper handling of the treatment cart and foley catheter. The Director of Nursing acknowledged that the LPN had not received specific training for her role and assumed that the LPN knew the correct positioning for foley catheters. The DON expressed an intention to provide the LPN with a bedside table for treatment supplies and additional education, but these actions were not yet implemented at the time of the report.
Failure to Develop Care Plan for Pressure Ulcers
Penalty
Summary
The facility failed to develop and implement a care plan for a resident with multiple pressure ulcers, which is a deficiency in their care planning process. The facility's policy, titled IDT/Care Plan Activities, mandates that nursing services update care plans as changes occur and communicate these updates with the MDS Coordinator and appropriate staff. However, upon review, it was found that there was no care plan in place for the resident's pressure ulcers, despite the resident having a diagnosis of stage 4 pressure ulcers on the left hip and right buttock, and a stage 2 pressure ulcer on the left heel. The resident, who has multiple sclerosis and a BIMS score indicating moderate cognitive impairment, had two stage 4 pressure ulcers present upon admission. The absence of a care plan was confirmed during an interview with the Administrator, DON, and ADON, who acknowledged that a care plan should have been developed to address the resident's pressure ulcers. This oversight had the potential to prevent the resident from receiving necessary care and services to maintain the highest quality of life possible.
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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