Archway Transitional Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Macon, Georgia.
- Location
- 4373 Houston Avenue, Macon, Georgia 31206
- CMS Provider Number
- 115728
- Inspections on file
- 22
- Latest survey
- January 16, 2026
- Citations (last 12 mo.)
- 5 (2 serious)
Citation history
Health deficiencies cited at Archway Transitional Care Center during CMS and state inspections, most recent first.
A cognitively impaired resident with hemiplegia and severe communication deficits was not adequately protected from sexual abuse by a severely cognitively impaired roommate with dementia and psychiatric history. Staff observed the roommate at the bedside with his penis exposed and masturbating near the resident, attempted redirection, and notified supervisory staff, law enforcement, and an NP. However, despite facility policies requiring immediate protection of alleged victims, increased supervision, and possible room or staffing changes, the two residents continued to share a room while staff relied on hourly checks and environmental measures, and the alleged victim later reported a prior similar incident that had not been reported to staff.
Administration and nursing leadership failed to protect a resident from alleged sexual abuse by a roommate and did not provide adequate safeguards during the subsequent investigation. Despite job descriptions assigning the Administrator and DON responsibility for abuse prevention and regulatory compliance, the two residents were kept in the same room, and the facility relied on hourly monitoring rather than separating them. The Administrator reported that the resident was not sent to the ER because an NP did not order it, and the DON initially agreed with the hourly monitoring interventions based on the aggressor’s prior behavior history. The situation was later determined to constitute Immediate Jeopardy due to noncompliance with requirements intended to prevent abuse.
The facility failed to timely report an allegation of resident-to-resident physical abuse to the State Survey Agency (SSA) as required by its abuse reporting policy. A nurse documented that two residents were involved in an altercation in the dining room in which one resident reportedly walked up to another and began hitting him in the head, after which the aggressor was escorted back to his room and assessed for injury. The facility’s incident report and subsequent follow-up to the SSA listed an incorrect incident date, causing the allegation to be reported outside the required 2-hour window. During interview, the Administrator could not explain why the incident report was submitted late.
Staff did not ensure that resident room and dining room furniture was maintained in good repair, with multiple armchairs and dressers found damaged and all dining room chairs observed to have torn or missing upholstery and exposed cushioning. Facility leadership confirmed the need for repairs, and records showed ongoing requests for new furniture and parts, but no documented work orders or inspections.
Staff failed to ensure the medication error rate remained below five percent, with three errors observed among 35 opportunities. Errors included administering an incorrect dose of an inhaler to a resident with heart and lung conditions, preparing an expired allergy medication for a resident with multiple chronic illnesses, and incorrectly administering a disintegrating antipsychotic tablet. Nursing staff confirmed these were medication errors.
A resident with cognitive impairment and psychiatric diagnoses alleged sexual abuse by another resident during a hospital stay. Although law enforcement and the resident's family were notified, facility staff did not report the allegation to the State Survey Agency as required by policy, instead deciding internally that it was not a reportable event.
The facility failed to maintain a sanitary dumpster area, as two dumpster lids were damaged and debris was present. Staff interviews revealed a lack of awareness and communication regarding responsibilities for maintaining the area. The Maintenance Director and Dietary Manager confirmed the observations, while the Housekeeper Supervisor and Administrator were unaware of the issues.
A resident with COPD was observed receiving oxygen at 2.5 LPM instead of the prescribed 2.0 LPM. The facility's policy requires adherence to physician orders for oxygen therapy, which was not followed in this case. The DON confirmed the discrepancy during an observation and interview.
Failure to Protect Cognitively Impaired Roommate From Sexual Abuse and Inadequate Protection During Investigation
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident (R1) from sexual abuse by his roommate (R2) and to provide adequate protection for R1 during the subsequent investigation. R1 had major depressive disorder, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, a cognitive communication deficit, muscle weakness, and a contracture of the right hand. His admission MDS showed a BIMS score of 5, indicating severe cognitive impairment. R2 had diagnoses including insomnia, major depressive disorder recurrent severe without psychotic features, a history of non‑suicidal self‑harm, and unspecified dementia with psychotic disturbance, with a five‑day MDS BIMS score of 2, also indicating severe cognitive impairment. On the evening of 12/20/2025, CNAs observed R2 standing at R1’s bedside with his penis out of his pants, moving his hands in an up‑and‑down motion near R1. The CNAs attempted to redirect R2 to the restroom and then to his side of the room, but he refused to enter the restroom and, after being guided back and separated by a privacy curtain, he snatched the curtain back and sat in a chair at R1’s bedside. When the LPN entered, R2 was seated on R1’s side of the room. The LPN questioned R2 about exposing himself, which he denied, and assessed R1, who denied that R2 had touched him, pulled back his covers, or touched him with his private parts. Nursing notes documented that the Administrator and DON were notified, law enforcement was contacted, and the NP was informed and initiated behavior protocol and a psychiatry referral. Despite the facility’s written Abuse Prohibition – Reporting and Investigating policy requiring immediate response to protect the alleged victim, increased supervision of the alleged victim and residents, and possible room or staffing changes at the discretion of administrative staff, R2 remained in the same room with R1 following the incident. Hourly checks and keeping the door open with the privacy curtain pulled were implemented, but R1 and R2 continued to share the room for several days after the event. In a later interview, R1 reported that his roommate had previously sat on his bed near the foot of the bed, naked from the waist down with his penis in his hand, and that he told him to leave but did not report the incident to staff. The facility’s actions and inactions, including not immediately separating the residents and relying on hourly monitoring while both residents with severe cognitive impairment remained roommates, failed to provide the level of protection outlined in the facility’s abuse policies.
Failure to Protect Resident From Sexual Abuse and Inadequate Safeguards During Investigation
Penalty
Summary
Administration failed to maintain an environment free from sexual abuse and to provide adequate protection during the investigation of an alleged sexual abuse incident involving two residents sharing a room. The Administrator’s job description assigned responsibility for directing day-to-day operations in compliance with regulations and assuming responsibility for procedural guidelines related to prevention and reporting of patient abuse, while the DON’s job description assigned responsibility for directing nursing services in accordance with applicable regulations. Despite these responsibilities, after an allegation that one resident sexually abused their roommate, the facility did not remove the alleged aggressor from the room or otherwise separate the residents at the time of the incident. The Administrator later stated that the facility did not send the alleged victim to the ER because the NP did not issue an order to do so and only ordered a psychiatry referral. The DON reported that evening staff notified her of the incident and explained the interventions that had been put in place, including hourly monitoring, which she initially considered appropriate because the alleged aggressor had not previously exhibited such behavior and was described as usually well-mannered. The Administrator stated she decided to implement hourly monitoring and believed the facility had done everything needed to keep the alleged victim safe, emphasizing that the alleged aggressor had no prior history of such behavior. However, both residents continued to reside in the same room from the date of the incident until surveyors questioned the Administrator about placement options for the alleged aggressor, at which point the alleged victim was moved to a different room. The noncompliance was determined to have the likelihood to cause serious injury, harm, impairment, or death and was identified as Immediate Jeopardy beginning on a specific date.
Failure to Timely Report Allegation of Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to timely report an allegation of physical abuse to the State Survey Agency (SSA) as required by its own policy and federal expectations. The facility’s Abuse Prohibition – Reporting and Investigation policy, revised 12/27/2024, states that all allegations of abuse or those involving serious bodily injury must be reported immediately, but no later than 2 hours. A nurse’s note for Resident 6 dated 12/12/2025 at 7:36 p.m. documented that the nurse was summoned to the dining room regarding an altercation between Resident 6 and another male resident (Resident 7), during which witnesses stated that Resident 6 walked up to Resident 7 and started hitting him in the head. Resident 6 was escorted back to his room and assessed, and bleeding was noted from the index finger on the right hand from a previous injury. However, the Facility Incident Report Form (FRI) was completed with the incident date and time recorded as 12/13/2025 instead of 12/12/2025, and the follow-up report submitted to the SSA on 12/19/2025 also identified the incident date as 12/13/2025. This incorrect dating resulted in the allegation of abuse not being reported to the SSA within the required 2-hour timeframe from the actual occurrence on 12/12/2025. During an interview on 1/7/2026 at 11:35 a.m., the Administrator stated she was not sure why the FRI was reported late.
Failure to Maintain Resident and Dining Room Furniture in Good Repair
Penalty
Summary
Facility staff failed to maintain resident room and dining room furniture in good repair, as evidenced by observations of seven armchairs in resident rooms and the day room with missing and torn upholstery, exposing cushion material on seats, arms, and backs. Dressers in resident rooms were also found with broken handles and missing drawer fronts. In the dining room, all 55 chairs were observed to be in disrepair, with torn or missing upholstery and exposed or missing cushioning, including four chairs with missing arm padding that left sharp metal corners exposed. These conditions were confirmed during interviews with the Administrator and Maintenance Supervisor, who acknowledged the need for repairs and stated that parts had been ordered but not yet delivered. Review of facility records and email correspondence revealed that requests for new furniture and replacement parts had been made to the corporate office over a period of two years. However, there was no evidence of furniture repair requests or inspections documented in the facility's electronic system. The Maintenance Supervisor indicated that work orders for furniture repairs had not been received, and the Administrator noted that chairs with missing armrests had been removed but continued to reappear in the building. The failure to maintain furniture in good repair was directly observed and confirmed by facility leadership.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required by policy, resulting in three medication administration errors out of 35 observed opportunities. For one resident with hypertensive heart disease, pulmonary hypertension, and dementia, a Certified Medication Aide (CMA) administered two puffs of Anoro Ellipta inhaler instead of the prescribed one puff. The CMA acknowledged the error after administration. For another resident with Guillain-Barre syndrome, chronic respiratory failure, and COPD, a CMA prepared loratadine from an expired container and was preparing to administer it before being stopped by a surveyor. Additionally, the same CMA administered an olanzapine disintegrating tablet without instructing the resident to allow it to dissolve in the mouth, resulting in the resident swallowing the tablet whole. Both the CMA and supervisory nursing staff confirmed these were medication administration errors.
Failure to Report Alleged Sexual Abuse to State Survey Agency
Penalty
Summary
The facility failed to report an allegation of abuse to the State Survey Agency as required by its own policy. A resident with diagnoses including paranoid schizophrenia, generalized anxiety disorder, and hallucinations, and who was assessed as cognitively impaired, was hospitalized following a fall. During her hospital stay, she alleged that she had been raped multiple times by another resident approximately six weeks prior. The hospital notified law enforcement, the resident's family, and a facility RN of the allegation. However, there was no evidence that the facility reported this allegation to the State Survey Agency. Interviews with facility staff confirmed that the Director of Nursing and Administrator were made aware of the allegation via text message, and the matter was discussed in a staff meeting. The staff decided not to report the allegation to the State Survey Agency, believing it was not a true reportable event. This decision was made despite the facility's policy requiring immediate reporting of all abuse allegations, and no initial report was submitted to the State Survey Agency regarding the resident's rape allegation.
Unsanitary Dumpster Area Due to Damaged Lids and Debris
Penalty
Summary
The facility failed to maintain the dumpster area in sanitary conditions, as observed during a survey. The facility's policy on storage areas required that the dumpster area be free of trash and debris, and that containers be kept in good condition and covered. However, observations revealed that two of the three dumpster lids were badly damaged, preventing secure closure. Additionally, broken pallet pieces and large pallets covered with dirt and debris were found on the ground between two dumpsters. These conditions were confirmed by the Dietary Manager and the Maintenance Director during the survey. Interviews with facility staff revealed a lack of awareness and communication regarding responsibilities for maintaining the dumpster area. The Maintenance Director stated that vendors deliver supplies on pallets every Tuesday, and the Housekeeping Staff were supposed to unload the delivery truck and place the pallets in the dumpsters. However, the Housekeeper Supervisor was unaware that her staff was assigned this task. The Administrator also reported being unaware of the damaged lids and the presence of broken pallets on the ground, although she expected staff to maintain the dumpster area in a sanitary manner and report any damages or concerns.
Oxygen Therapy Not Administered Per Physician's Order
Penalty
Summary
The facility failed to administer oxygen therapy to a resident in accordance with the physician's order. The resident, who has a diagnosis of chronic obstructive pulmonary disease (COPD), was observed receiving oxygen via a nasal cannula at 2.5 liters per minute (LPM) instead of the prescribed 2.0 LPM. This discrepancy was noted during observations on two separate occasions. The facility's policy on the use of oxygen therapy requires that oxygen be administered as per the physician's order, which in this case specified 2.0 LPM for shortness of breath or wheezing. The Director of Nursing (DON) confirmed the deviation from the physician's order during an observation and interview, acknowledging that the resident was receiving a higher oxygen flow than prescribed.
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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