Archbold Living Camilla
Inspection history, citations, penalties and survey trends for this long-term care facility in Camilla, Georgia.
- Location
- 37 South Ellis Street, Camilla, Georgia 31730
- CMS Provider Number
- 115266
- Inspections on file
- 17
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 6 (2 serious)
Citation history
Health deficiencies cited at Archbold Living Camilla during CMS and state inspections, most recent first.
A cognitively impaired resident with Alzheimer’s disease and a severely impaired BIMS score was not protected from sexual assault by another cognitively impaired resident. A CNA first saw the alleged perpetrator in his wheelchair at the doorway of the resident’s room, and later found the room door closed with him inside next to the bed. After an LPN and CNA re-entered the room, they discovered the resident’s brief near the pillow, the resident naked from the waist down, and blood on the sheets and in the vaginal area. The resident was later found on SANE exam to have vaginal penetration and a vaginal wall laceration. The other resident was found with dried blood on his right middle finger and told law enforcement he had inserted his fingers into the resident’s vagina, indicating the facility failed to effectively implement its abuse prevention and sexual abuse identification policies to protect the resident from non-consensual sexual contact.
Administration failed to protect a severely cognitively impaired resident from sexual assault by another severely cognitively impaired resident, despite policies requiring residents be free from abuse and that leadership maintain a safe, secure environment. A CNA and an LPN discovered the victim’s brief removed, the resident naked from the waist down, and blood on the sheets and in the vaginal area; a subsequent SANE exam confirmed vaginal penetration and a vaginal wall laceration. Law enforcement documented that the alleged perpetrator admitted placing his fingers into the resident’s vagina and noted dried blood on his finger, while the Administrator reported there had been no prior behavioral indications in the perpetrator’s history that would have led the facility to decline his admission.
The facility failed to follow its falls management policy by not consistently completing fall risk assessments, 3‑day post‑fall follow‑ups, and neurological checks for four residents with multiple witnessed and unwitnessed falls. Residents with conditions such as Alzheimer’s disease, dementia, cerebral infarction, hemiplegia, and unsteadiness on feet had falls documented in nursing notes, but required 3‑day post‑fall monitoring was often missing, and neuro checks were incomplete or not done per required timing. One resident identified by PT as a fall risk had no fall risk assessments in the record, and another had outdated fall risk assessments with none documented for two consecutive years. Staff interviews confirmed that policy required post‑fall follow‑up and neuro checks for unwitnessed falls or head injuries, yet documentation was absent or incomplete, and the DON reported that EMR issues prevented automatic triggering of post‑fall follow‑ups and electronic completion of neuro checks.
A resident with multiple comorbidities, moderate cognitive impairment, dependence in toileting hygiene, and a history of a sacral pressure ulcer was observed receiving perineal care from an LPN who did not follow infection control practices. The PPE container outside the room lacked gowns, and the LPN entered without a gown despite the presence of loose stool that had leaked from the resident’s brief. During incontinence care, the LPN used wipes in a manner that spread stool from soiled areas to previously cleaned buttock and sacral areas and did not re-clean those areas. In a later interview, the LPN confirmed she had reused a dirty wipe on a clean area, had no bag for soiled items, did not re-clean the sacral and buttock area, and acknowledged she had not performed the procedure correctly or worn the required gown.
An LPN was observed pre-setting medications in labeled cups for multiple residents, contrary to facility policy requiring individual administration and verification. This practice resulted in a medication error rate of 55.56%, including a missed dose of Atorvastatin for a resident. Interviews confirmed the LPN was aware of the policy and had been previously warned, and both the DON and Administrator reiterated that pre-setting medications is not permitted.
Surveyors identified expired OTC medications and prescription drugs in medication storage rooms and on medication carts in two facilities. Expired probiotics, suppositories, aspirin, thiamine, ibuprofen, ferrous sulfate, [NAME]-Vite tablets, and Lantus insulin were found. Staff interviews confirmed that nurses and a secretary were responsible for checking expiration dates, but expired medications remained accessible.
Kitchen staff did not allow pans to fully air-dry before stacking, resulting in wet pans being stored, and the dishwasher failed to dispense soap due to a clogged dispenser. These issues were confirmed by the NSD and DM, with expectations for proper cleaning and equipment function reiterated by the Administrator.
Facility A did not ensure that garbage and refuse were properly disposed of and contained in building B. Surveyors observed dumpsters with open lids and doors, trash including old chairs behind the dumpsters, a trash can filled with unbroken boxes, and empty oil jugs left on the ground instead of being placed in the dumpsters. These conditions were acknowledged by both the DM and the Administrator as not meeting facility policy.
Facility B did not maintain a Legionella Water Management Program as outlined in its policy, lacking both a water system diagram and a detailed description. Engineering staff acknowledged the absence of these required elements, and the administrator confirmed the expectation to follow policy and CMS guidelines.
Facility B did not maintain documentation of staff COVID-19 vaccination status. Interviews with the DON and Administrator confirmed that, despite providing education, the facility lacked records showing whether staff were immunized. This affected all residents and staff.
The facility did not properly monitor or evaluate antibiotic use for several residents, with antibiotics being prescribed without meeting McGeer Criteria or following appropriate diagnostic protocols. Staff interviews revealed a lack of oversight and understanding of antibiotic stewardship requirements, leading to noncompliance with both CDC guidance and facility policy.
Two residents were administered psychotropic medications without being informed of the risks and benefits, as required by facility policy. Consent forms were signed by representatives prior to admission but did not include specific information about medication risks and benefits. Facility staff confirmed that education on these medications was not documented or provided prior to administration.
Two residents who were cognitively intact were not invited to attend or participate in their care plan conferences, as required by facility policy. Both residents reported never being asked to attend, and care plan conference records lacked their signatures. The Activity Director confirmed that invitations were not distributed, despite expectations from the DON and Administrator that residents be included in these meetings.
A resident was not properly provided with the required CMS-10055 and CMS-10123 Medicare coverage notices when Part A services ended. The facility emailed the forms to the resident's POA but did not follow up after receiving no response, resulting in the resident or representative not being able to review the notices or make informed decisions about continued therapy or appeals.
A resident with hemiplegia and hemiparesis did not have their quarterly MDS assessment data submitted to CMS in a timely manner. The MDS Coordinator completed and initially submitted the assessment, but failed to confirm its acceptance and did not recognize the missing submission until prompted by a surveyor, resulting in a delay beyond the required timeframe.
Two residents using three-quarter bed rails did not have care plans addressing this intervention, despite facility policy and staff expectations that such use should be documented. Staff interviews confirmed the omission, and the absence of care plan documentation for bed rail use placed these residents at risk for unmet care needs and increased accident risk.
A resident's care plan was not updated to reflect healed pressure ulcers, discontinued use of a low air loss mattress, and a change to NPO status with tube feedings. Despite documentation and staff confirmation of these changes, the care plan continued to reference outdated interventions and needs, contrary to facility policy requiring timely care plan revisions.
A resident who was dependent on staff for ADLs did not receive showers as preferred, instead receiving repeated bed baths without documented refusals or requests for bed baths. Staff interviews confirmed that showers were not consistently offered and refusals were not documented, contrary to facility policy.
A resident with severe cognitive impairment and a gastrostomy developed a Stage II pressure ulcer at the PEG tube site, which was not identified during routine skin assessments or care. The ulcer was discovered only after a note prompted the wound care LPN to check under the plastic bumper, where no gauze or foam had been placed. Facility policy required regular skin inspections, but the deficiency occurred due to failure to detect and prevent the ulcer as per standard care.
A resident with multiple medical conditions repeatedly struck her hand on a protruding bathroom door protector after a temporary duct tape fix was not monitored or maintained. Staff were aware of the hazard, but the interim intervention was not checked, leaving the resident at risk until a permanent repair could be made.
Two residents were provided bed rails without prior assessment, risk/benefit review, or informed consent, as required by facility policy. Staff interviews confirmed a lack of awareness regarding the need for assessment and consent before bed rail use, and documentation was missing for both residents. One resident was unable to lower the bed rails independently, and another requested their use, but neither had the required evaluation or consent process completed.
A nurse crushed and administered Potassium Chloride ER, ferrous sulfate, and gabapentin to three residents, despite manufacturer and facility guidelines prohibiting this practice. This resulted in a medication error rate of 12%, exceeding the acceptable threshold. Staff interviews confirmed these medications should not have been crushed.
A resident with Alzheimer's disease under hospice care experienced a decline and was found deceased after receiving morphine. An LPN failed to document the resident's decline, death, and disposition in the EMR, contrary to facility policy. The administrator confirmed that documentation of the resident's condition and events up to the time of death was expected but not completed.
Failure to Protect Cognitively Impaired Resident From Sexual Assault by Another Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from sexual assault by another cognitively impaired resident, despite policies on abuse prohibition and identifying sexual abuse and capacity to consent. The facility’s Abuse Prohibition Policy and Procedures required identification, correction, and intervention in situations where abuse was more likely to occur, including monitoring residents with aggressive or intrusive behaviors. The Identifying Sexual Abuse and Capacity to Consent policy stated that consent is not valid if a resident lacks capacity or if there is reason to suspect the resident does not wish to engage in sexual activity, and required investigation and protection when non-consensual sexual relations were suspected. The resident who was assaulted had Alzheimer’s disease and a BIMS score of three, indicating severe cognitive impairment, and therefore lacked capacity to consent to sexual activity under the facility’s own policy. On the day of the incident, a CNA initially observed the alleged perpetrator resident sitting in his wheelchair in the doorway of the cognitively impaired resident’s room while she was in bed watching television. Later, the CNA noticed that the resident’s door was closed and, upon opening it, saw the same resident in his wheelchair inside the room next to the bed. The CNA closed the door and went to get an LPN to verify whether it was appropriate for him to be in the room. When the CNA and LPN entered the room together, they saw the resident in bed with a jacket and shirt on and a sheet covering her from the waist down, and did not initially notice anything unusual. After they left the room, the CNA asked the LPN if she had seen a brief near the pillow; when the LPN said she had not, they re-entered the room and observed the brief by the pillow. During the subsequent assessment, the LPN pulled back the sheet and found the resident naked from the waist down, with blood noted on the sheets and a moderate amount of blood in the vaginal area, including dried blood on the outer vaginal skin. The CNA reported that when she began placing a new brief on the resident, blood began to leak onto the brief, and a second brief showed a yellow discharge. The resident was sent to the hospital, where a SANE examination documented vaginal penetration and a one-centimeter laceration to the left vaginal wall. The other resident involved, who had a BIMS score of five indicating severe cognitive impairment, was found to have dried red blood on his right middle finger, and later told law enforcement that he had placed his fingers into the resident’s vagina while in her room with the door closed. These events demonstrate that the facility did not effectively implement its abuse prevention and sexual abuse identification policies to protect the resident from non-consensual sexual contact.
Failure to Protect Resident From Sexual Assault by Another Resident
Penalty
Summary
Administration failed to ensure that a resident was protected from sexual assault and maintained in an environment free from abuse, as required by the facility’s Resident Rights policy and the performance standards for the Nursing Home Administrator and Director of Nursing. The resident (R1) had diagnoses including Alzheimer’s disease, hypothyroidism, and atherosclerotic heart disease, and an MDS BIMS score of three indicating severe cognitive impairment. On the date of the incident, a CNA observed R1’s room door closed, opened it, and saw another resident (R2) in his wheelchair next to R1’s bed. When the CNA returned with an LPN, they found R1’s brief lying next to her pillow, and R2 was removed from the room. Upon assessment, the LPN noted that R1 was naked from the waist down, with blood on the sheets, a moderate amount of blood in the vaginal area, and dried blood on the outer vaginal skin. R1 was sent to the hospital, where a SANE examination documented vaginal penetration with associated vaginal bleeding and a one-centimeter laceration to the left vaginal wall. R2’s medical record showed diagnoses including dependence on renal dialysis, end stage renal disease, cardiac arrhythmia, hypertension, and syncope and collapse, with an MDS BIMS score of five, also indicating severe cognitive impairment. A police department incident report documented that, when questioned by law enforcement, R2 stated he had positioned his wheelchair beside R1’s bed and placed his fingers into R1’s vagina, and the officer observed dried, stained blood on R2’s right finger. The Administrator stated there had been no indication of behaviors in R2’s past medical history that would have led the facility to decline his admission and that there was no indication of behaviors that would have triggered concern about such an outcome. The facility’s failure to ensure R1 was free from abuse and to maintain a safe and secure environment resulted in an Immediate Jeopardy determination related to the resident’s physical, mental, and psychosocial well-being.
Failure to Complete Fall Risk Assessments, Post‑Fall Follow‑Ups, and Neuro Checks
Penalty
Summary
The deficiency involves the facility’s failure to follow its Falls and Falls Risk Management policy by not consistently completing fall risk assessments, 3‑day post‑fall follow‑ups, and neurological checks for four residents with documented falls. The policy requires staff, with physician input, to identify interventions based on evaluations and current data, and to monitor and document each resident’s response to interventions intended to reduce falls and fall risk. However, for multiple residents with diagnoses such as Alzheimer’s disease, dementia, cerebral infarction, hemiplegia, and unsteadiness on feet, the required assessments and monitoring were either missing or incomplete. One resident with Alzheimer’s disease, dementia, diabetes, and unsteadiness on feet experienced multiple unwitnessed falls in the hallway and in her room. Nursing notes documented falls on several dates, including one with redness to the left foot and a skin tear to the left elbow, but there was no evidence of any 3‑day post‑fall follow‑up for these events. Neurological checks initiated after one unwitnessed fall were incomplete and did not follow the required timing protocol, and there was no evidence of any fall risk assessments in the medical record despite a physical therapy assessment identifying the resident as a fall risk. Another resident with cerebral infarction, hemiplegia, hypertension, adult failure to thrive, and chronic pain had multiple unwitnessed falls in his room and bathroom. For these falls, neurological checks were incomplete and not done per timing protocol, and 3‑day post‑fall follow‑ups were not completed. Fall risk assessments were only documented in early 2023, with no evidence of updated assessments for 2024 and 2025. A third resident with palliative care needs, cerebral infarction, hypertension, and dysphasia had a witnessed fall documented in nursing notes, but there was no evidence of a 3‑day post‑fall follow‑up. An LPN confirmed that after a fall, a 3‑day post‑fall follow‑up should have been completed and that fall risk assessments were expected on admission and with monthly summaries, as well as neurological checks for unwitnessed falls or head injuries. A fourth resident with Alzheimer’s disease, dementia, and hypertension had unwitnessed falls documented in nursing notes, including one where a roommate called for help. Although the RN reported assessing the resident, obtaining vital signs, and documenting follow‑up under a fall charting tab, there was no evidence of a complete 3‑day post‑fall follow‑up for one of the falls, and neurological checks were incomplete and not done according to the required timing protocol. The care plan listed a fall but lacked additional documentation related to that fall. The DON and Administrator acknowledged expectations that assessments and neurological checks be completed per the fall policy and noted issues with the electronic medical record not triggering required follow‑ups and not allowing neuro checks to be completed electronically.
Improper Perineal Care and Infection Control During Incontinence Care
Penalty
Summary
Failure to provide sanitary perineal care occurred when a nurse did not follow infection prevention and control practices while cleaning a resident with loose stool and a history of a sacral pressure ulcer. The facility’s perineal care policy stated that dependent patients should receive cleansing of the perineum following voiding or defecation to promote healing and comfort. The resident involved had diagnoses including Alzheimer’s disease, heart failure, rhabdomyolysis, cerebral infarction, and hemiplegia/hemiparesis, and was assessed as having moderate cognitive impairment and dependence with toileting hygiene. The resident had a history of a sacral pressure ulcer that had been documented as resolving and then closed on weekly skin assessments. During an observation, an LPN entered the resident’s room, which had an enhanced barrier sign posted and an infection control PPE container on the door that contained only a partially filled bottle of hand sanitizer and no gowns. The resident was lying on an airflow mattress with loose stool between her thighs that had leaked from her brief. The LPN did not don a protective gown despite the presence of loose stool and proceeded to roll the soiled brief toward the back and begin cleaning the front perineal area. After turning the resident to her side, the LPN removed the rolled brief, used a clean wipe to clean the buttocks and sacral area, then used another wipe to clean between the thighs where loose stool had settled, and with that same soiled wipe wiped again over the buttocks and sacral area. In a subsequent interview, the LPN acknowledged that she did not have a bag for dirty items, confirmed she had wiped a clean area with a dirty wipe, did not re-clean the sacral and buttock area, and admitted she did not perform the procedure correctly and did not wear a gown as she was supposed to.
Improper Pre-Setting of Medications by LPN Leads to High Medication Error Rate
Penalty
Summary
Facility B failed to ensure proper medication administration practices by allowing an LPN to pre-set medications in labeled cups for multiple residents on one hall. Observations revealed that the LPN placed six plastic cups labeled with room numbers and bed letters on top of the medication cart, each containing medications for specific residents. Review of physician orders and medication administration records showed that the LPN administered medications as indicated for several residents, but one resident did not receive a scheduled medication (Atorvastatin), resulting in a medication error rate of 55.56%. The facility's policy requires that medications be administered in a safe and timely manner, with verification of the right resident, medication, dosage, time, and route immediately before administration. During interviews, the LPN admitted to pre-setting medications and acknowledged being previously instructed by the pharmacist consultant not to do so. The DON and Administrator both confirmed that facility expectations prohibit pre-setting and labeling medication cups in advance, requiring nurses to administer medications individually per resident. The deficiency was identified through direct observation, record review, and staff interviews, confirming non-compliance with facility policy and standard medication administration procedures.
Expired Medications Found in Storage Rooms and Medication Carts
Penalty
Summary
Facility A failed to ensure that expired over-the-counter (OTC) medications were not present in the medication storage room and on two medication carts. During observations, surveyors found a bottle of probiotic formula and a jar of Fleet glycerin suppositories, both expired, in the medication storage room. On the Long Hall medication cart, several bottles of aspirin and thiamine B-1 vitamins were found to be expired. The Short Hall medication cart also contained expired aspirin, ibuprofen, and a bottle of ferrous sulfate with an illegible expiration date. Interviews with nursing staff and the Director of Nursing (DON) revealed that nurses were responsible for checking medication carts for expired medications, while a secretary was tasked with checking OTC medications in the storage room. Facility B was also found to have expired medications in one of its medication storage rooms and on a medication cart. In the Bluebird Hall medication storage room, a bottle of thiamine vitamin B-1 was expired. On the 100 Hall medication cart, expired [NAME]-Vite tablets and a vial of Lantus insulin past its expiration date were found. The DON confirmed the expired status of the insulin. These findings indicate that both facilities did not adhere to their own policies regarding the storage and timely removal of expired medications.
Improper Air-Drying of Pans and Dishwasher Soap Dispensing Failure
Penalty
Summary
Facility B failed to ensure that kitchen staff thoroughly cleaned and air-dried pans prior to storage, as required by facility policy. During an observation, 14 pans that had been cleaned and stacked for use were found to be wet and had not been allowed to completely air dry before stacking. The Nutritional Services Director confirmed that the pans should have been completely dry before being stacked and acknowledged that they needed to be re-washed. Additionally, the facility failed to ensure that soap was dispensing into the dishwasher after replacing the dish detergent. During an observation, it was noted that soap was not coming out of the dispenser into the dishwasher, and upon inspection, the dispenser was found to be clogged. After replacing the bottle, the soap flowed into the dishwasher. The Dietary Manager confirmed that the dishwasher had not dispensed soap as expected, and the Administrator stated that the expectation was for the dishwasher to be in working order and for dishes to be cleaned properly.
Improper Disposal and Containment of Garbage in Building B
Penalty
Summary
Facility A failed to ensure proper disposal and containment of garbage and refuse in one of its buildings, specifically building B. During an observation behind the kitchen, surveyors found two dumpsters with their lids and side compartment doors open, trash including old chairs behind the dumpsters, a trash can filled with unbroken boxes, and six empty 35-gallon plastic oil jugs lying on the ground instead of being disposed of in the dumpsters. The facility's policy requires dumpsters to be kept closed and the area to be kept clean to prevent contamination and pest transmission. Both the Dietary Manager and the Administrator confirmed that the observed conditions did not meet facility expectations or policy requirements.
Failure to Maintain Legionella Water Management Program
Penalty
Summary
Facility B failed to maintain a Legionella Water Management Program as required by its own policy. The facility's policy, dated 08/20/22, specifies the need for a detailed description and diagram of the water system to identify and control areas where Legionella bacteria could grow and spread. During interviews, the engineering staff confirmed that neither a water diagram nor a detailed description of the water system existed for the facility, acknowledging awareness of the requirement but stating it had not been completed. The administrator also confirmed the expectation that the facility should follow its policy and CMS guidelines.
Failure to Document Staff COVID-19 Vaccination Status
Penalty
Summary
Facility B failed to maintain documentation of current COVID-19 vaccination status for its staff members. Interviews with the Director of Nursing (DON) and the Administrator revealed that the facility did not have records indicating whether staff were immunized or not, and both were unaware of the requirement to keep such documentation. Although education on COVID-19 vaccination was provided, there was no system in place to track or document the vaccination status of staff members. This deficiency had the potential to affect all 132 residents and all staff in the facility.
Failure to Monitor and Evaluate Antibiotic Usage per Stewardship Program
Penalty
Summary
The facility failed to monitor and evaluate antibiotic usage for five of seven residents reviewed for antibiotic use, as required by both CDC guidance and the facility's own Antibiotic Stewardship policy. Specifically, antibiotics were prescribed and administered to residents without adherence to McGeer Criteria, and in several cases, laboratory results such as urine cultures were negative or contaminated, yet antibiotics were still initiated. For example, one resident was started on Amoxicillin despite a negative culture, another was given Bactrim after a contaminated culture that was not repeated, and others received antibiotics for respiratory or urinary issues without meeting established criteria or having appropriate diagnostic testing completed. Interviews with facility staff revealed a lack of questioning or oversight regarding physician antibiotic orders, with the Infection Preventionist acknowledging that antibiotics are often started before culture results are available and that there is a need to follow McGeer Criteria and educate staff. The Medical Director admitted to not fully understanding the purpose of antibiotic stewardship, and the Administrator recognized the need to track antibiotic usage and adhere to policies. These actions and inactions resulted in the facility not effectively monitoring or evaluating antibiotic use as required.
Failure to Inform Residents of Risks and Benefits of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents were fully informed and understood the risks and benefits of psychotropic medication use prior to administration. According to the facility's policy, residents have the right to participate in decision-making regarding their care, which includes being informed about their health status, care, and treatments. However, for two residents reviewed, there was no evidence that the risks and benefits of psychoactive medications were explained to them or their representatives before the medications were administered. One resident, who was cognitively intact and admitted with diagnoses including major depressive disorder, anxiety, and dementia, received multiple psychotropic medications such as antipsychotics and antidepressants. The consent form on file was signed by a representative prior to admission and did not specify the risks and benefits of the medications. During an interview, the resident confirmed that no one had explained the risks and benefits of her medications to her, and she expected the facility's doctor to do so. Another resident, who was severely cognitively impaired and admitted with diagnoses of dementia and depression, also received several psychotropic medications. The consent form for this resident was similarly signed by a representative before admission and lacked information about the risks and benefits of the medications. Facility staff, including the Infection Preventionist and the DON, acknowledged during interviews that the consent forms did not include this information and that it was their expectation that such education should have been provided prior to medication administration.
Failure to Invite Residents to Participate in Care Plan Conferences
Penalty
Summary
Facility B failed to ensure that residents were informed in advance of their right to attend and participate in their care plan conferences, as required by facility policy and federal regulations. Specifically, two residents were not invited to their care plan meetings, and documentation showed that their signatures were absent from care plan conference records, indicating non-attendance. Both residents were assessed as cognitively intact at the time of the deficiency, and each expressed a desire to participate in their care planning but reported never being invited or attending such meetings since admission. Interviews with facility staff confirmed that the responsibility for notifying and inviting residents to care plan conferences was not fulfilled. The Activity Director acknowledged not distributing invitations to the residents, and both the DON and Administrator stated it was their expectation that residents be invited to these meetings. Facility policies reviewed also emphasized the importance of resident participation in care planning, but these procedures were not followed for the two residents in question.
Failure to Provide and Follow Up on Required Medicare Coverage Notices
Penalty
Summary
Facility A failed to obtain and properly follow up on the required CMS-10055 Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) and CMS-10123 Notice of Medicare Non-Coverage (NOMNC) for one resident when Medicare Part A services ended. According to facility policy, these forms are necessary to inform Medicare patients about their potential financial responsibility for noncovered services and their right to appeal. The resident's last covered day under Part A was documented, and the required forms were emailed to the resident's power of attorney (POA) prior to the end of coverage. However, there was no response from the POA, and the facility did not conduct any follow-up to ensure receipt or completion of the beneficiary notification paperwork. As a result, the resident or their representative was not given the opportunity to review the forms and make an informed decision regarding continued therapy services or to appeal the facility's decision to discontinue Medicare Part A therapy.
Failure to Timely Submit MDS Assessment Data
Penalty
Summary
Facility A failed to provide a timely submission of a quarterly Minimum Data Set (MDS) assessment for one resident with a history of hemiplegia and hemiparesis following a cerebral infarction. The resident was admitted to the facility and had a quarterly MDS assessment with an Assessment Reference Date (ARD) of 02/24/25, which was completed on 02/25/25. However, the MDS 3.0 Missing OBRA Assessment Report indicated that the last accepted MDS assessment for this resident was dated 12/03/24, showing a gap in timely data submission. The MDS Coordinator reported completing and submitting the quarterly MDS assessment as required, but did not verify its acceptance by CMS through the validation report. The coordinator misunderstood the missing assessment report and did not recognize that the quarterly assessment had not been accepted, resulting in a delay in resubmission until prompted by a surveyor. The Director of Nursing stated that the expectation was for MDS assessments to be transmitted within 14 days of completion and for validation reports to be checked to ensure acceptance by CMS, as outlined in the CMS LTC RAI 3.0 User's Manual.
Failure to Develop Care Plans for Bed Rail Use
Penalty
Summary
Facility B failed to develop and implement care plans addressing bed rail use for two of four residents reviewed for care planning. Observations showed that both residents were lying in bed with raised bilateral three-quarter bed rails, but their care plans did not include any information regarding the use of these bed rails. Review of the facility's policies indicated that the care planning team is responsible for creating individualized, comprehensive care plans based on resident assessments, and that these care plans should guide daily care routines and be accessible to staff. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing, confirmed that the care plans for these residents did not reflect their use of bed rails, despite the expectation that such information should be included. The Administrator also acknowledged that residents with bed rails should have this reflected in their care plans. The lack of care plan documentation for bed rail use placed the residents at risk for unmet care needs and increased the risk of accidents.
Failure to Revise Care Plan Following Change in Resident Status
Penalty
Summary
Facility B failed to review and revise the care plan for one of four residents reviewed for care planning. Specifically, a resident who had previously been treated for pressure ulcers and was on a low air loss mattress had since healed and no longer had any wounds or pressure ulcers, as confirmed by a weekly skin assessment and staff interviews. Despite these changes, the resident's care plan continued to reference the presence of skin injuries, the use of a low air loss mattress, and indicated that the resident required assistance with eating by mouth, even though the resident was NPO and receiving tube feedings per physician orders. Interviews with facility staff, including the Infection Preventionist and the Director of Nursing, confirmed that the care plan did not accurately reflect the resident's current status. The care plan was not updated to remove references to healed wounds, the discontinued use of a low air loss mattress, or the resident's current nutritional status. This lack of timely review and revision of the care plan was inconsistent with the facility's own policy, which requires care plans to be updated to reflect changes in a resident's condition.
Failure to Provide Showers According to Resident Preference and Policy
Penalty
Summary
Facility B failed to ensure that a resident who was dependent on staff for activities of daily living (ADLs) received showers according to her preference and the facility's policy. The facility's policy required that showers or baths be given per schedule and that refusals be documented, including the reason. Review of the resident's records showed that she received multiple bed baths over a period of more than two months, with only one documented shower. There was no evidence in the documentation that the resident refused showers or requested bed baths instead. Interviews with staff confirmed that the resident was often given bed baths, and refusals of showers were not documented as required. The resident in question was assessed as severely cognitively impaired on one assessment, but later assessed as cognitively intact. She expressed a preference for showers over bed baths, stating that aides only gave her bed baths. Staff interviews revealed that the resident sometimes screamed or complained during showers, and that staff found it easier to provide bed baths depending on the resident's mood. Both the DON and Administrator confirmed that showers should have been offered per the resident's preference and refusals should have been documented, but this was not done.
Failure to Prevent and Timely Identify Pressure Ulcer at PEG Tube Site
Penalty
Summary
Facility A failed to prevent the development of a facility-acquired pressure ulcer in one resident who was at risk, as identified through interviews, record reviews, and policy review. The resident, who had severe cognitive impairment and diagnoses including palliative care, stroke, and gastrostomy status, was admitted with no open skin areas documented in weekly skin assessments. However, wound care documentation later identified a Stage II pressure injury at the PEG tube site, which was not detected until it had progressed to that stage. The facility's policy required skin inspections every shift, especially under medical devices, but the pressure ulcer was not identified during routine care or weekly assessments. Interviews with staff revealed that the pressure ulcer was discovered only after a note was left for the wound care nurse to examine the area under the PEG tube's plastic bumper. It was found that no gauze or foam was placed under the bumper, which is considered standard care, although not explicitly required by facility policy. The DON acknowledged that proper gastrostomy care, including the use of gauze or sponge, is covered during orientation and is standard practice. The administrator recognized the need for proper skin checks and adherence to policy and standards, but the deficiency occurred due to the failure to identify and prevent the pressure ulcer in a timely manner.
Failure to Monitor and Maintain Bathroom Door Protector Creates Accident Hazard
Penalty
Summary
Facility A failed to adequately monitor and maintain a resident's bathroom door protector, resulting in a potential accident hazard. A resident with diagnoses including Type 2 diabetes mellitus with hyperglycemia and atherosclerotic heart disease, who was cognitively intact, reported repeatedly hitting her hand on a protruding edge of the bathroom door protector. The issue was reported to the Unit Secretary, who submitted a maintenance work order. The Facilities Management Supervisor applied duct tape as a temporary fix and awaited a replacement door, but did not continue to monitor the interim solution. Subsequent observations revealed that the duct tape was no longer in place, and the door protector continued to protrude, posing a risk to the resident. Interviews confirmed that neither the Facilities Management Supervisor nor the Unit Secretary monitored the effectiveness or presence of the temporary intervention. The resident expressed concern about potential injury, and the deficiency persisted until the new door could be installed.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
Facility B failed to assess residents for the use of bed rails, review the risks and benefits with the residents or their representatives, and obtain informed consent prior to installing bed rails for two of seven residents reviewed for accidents and hazards. The facility's policy required an interdisciplinary assessment, consultation with the attending physician, and input from the resident or legal representative before bed rails could be used, as well as documented consent and education about risks and benefits. However, interviews with staff, including the Administrator, DON, and MDS Coordinator, confirmed that no assessments or consents were obtained for the residents in question, and staff were unaware of the requirement to do so. Observations showed that both residents were found in bed with raised bilateral ¾ bed rails, and one resident was unable to independently lower the rails. Record reviews indicated that one resident was severely cognitively impaired according to a recent MDS, while a subsequent assessment showed cognitive intactness. Staff interviews confirmed that the bed rails were in use and that one resident requested them, but there was no documentation of assessment or consent. The facility's failure to follow its own policy and regulatory requirements placed these residents at risk for injury and restraint.
Medication Error Rate Exceeds Acceptable Threshold Due to Improper Crushing of Medications
Penalty
Summary
Facility B failed to maintain a medication error rate below five percent, as required, during a medication administration observation. Out of 25 opportunities for error, three medication errors were identified, resulting in a medication error rate of 12%. Specifically, a registered nurse crushed and administered Potassium Chloride Extended Release (ER) to a resident with hypokalemia, ferrous sulfate to a resident with iron deficiency anemia, and gabapentin to a resident with peripheral neuropathy. These medications were crushed and mixed with applesauce before administration. Interviews with nursing staff and the facility administrator confirmed that these medications should not have been crushed, as per manufacturer recommendations and facility policy. The facility's policy and the pharmaceutical guidelines for each medication explicitly state that Potassium Chloride ER, ferrous sulfate, and gabapentin should not be crushed due to the risk of altering their intended release and absorption. The actions observed were not in accordance with manufacturer specifications or accepted professional standards.
Failure to Document Resident Decline and Death
Penalty
Summary
Facility A failed to document the decline, death, and disposition of a resident who was under hospice care and had a diagnosis of Alzheimer's disease. The facility's policy requires that the medical record provide a comprehensive account of the patient's health status, care provided, and serve as a legal record. However, review of the electronic medical record (EMR) for the resident showed only a note indicating release to a funeral home, with no documentation of the resident's decline or the circumstances surrounding the death. An LPN who was caring for the resident reported that after administering morphine and returning to the room, the resident was found unresponsive and subsequently pronounced deceased by the hospice nurse. The LPN acknowledged that, due to the situation, they did not document the resident's decline or death as required. The facility administrator confirmed the expectation that nurses document the resident's condition at the time of death and all events leading up to it, which was not done in this case.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
