Arrowhead Post Acute Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Jonesboro, Georgia.
- Location
- 239 Arrowhead Boulevard, Jonesboro, Georgia 30236
- CMS Provider Number
- 115539
- Inspections on file
- 19
- Latest survey
- June 12, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Arrowhead Post Acute Llc during CMS and state inspections, most recent first.
Surveyors identified multiple deficiencies in food safety and sanitation, including undated food items in the walk-in cooler, unclean kitchen equipment and surfaces, incomplete dish machine temperature logs, and improper handling and storage of ice scoops. These issues were confirmed by the Dietary Manager, ADON, and Administrator, and had the potential to affect all residents receiving oral diets from the kitchen.
Surveyors identified multiple deficiencies in 16 resident rooms and several common areas, including exposed electrical holes, broken furniture, water damage, mildew, missing fixtures, and accumulations of dirt and debris. Facility staff confirmed many of these issues had not been addressed or were previously unrecognized, with some problems persisting for weeks.
The facility did not maintain an effective pest control program, as evidenced by multiple residents reporting frequent sightings of roaches, water bugs, and gnats in their rooms and common areas. Despite documented complaints and a policy requiring ongoing pest management, pest control services were inconsistently provided, with significant gaps between treatments and continued pest activity noted during service visits.
Three residents who wished to vote were not provided with the necessary assistance or information to participate in elections, due to lack of follow-up, communication, and support from staff, as well as issues with identification and transportation.
A resident with cognitive capacity was not invited to participate in her person-centered care plan meetings. Despite multiple care plan revisions and the resident's ability to participate, there was no documentation or evidence that she was informed of or included in these meetings. Staff responsible for scheduling and documenting care plan meetings could not provide records showing the resident's invitation or participation.
A resident with a signed DNR order and hospice admission was incorrectly listed as full code in the EMR, care plan, physician's orders, and code status book. Multiple staff, including LPNs and the DON, relied on this inaccurate information and would have initiated CPR, contrary to the resident's documented wishes. Hospice nurses confirmed the resident's DNR status, but the facility's documentation and communication failures placed the resident at risk of not having end-of-life preferences honored.
Three residents with significant physical or cognitive impairments did not have comprehensive care plans addressing their documented needs. One resident's preferences for specific activities and management of lower extremity edema were not included in the care plan, another resident with contractures and pressure ulcers lacked a care plan for contracture management and pressure relief, and a third resident's activity preferences were not addressed in the care plan despite being assessed as important.
The facility did not ensure that care plans were properly developed, reviewed, and revised for several residents, including a resident with a history of stroke who did not receive prescribed heel protectors, a resident whose care plan conferences were not completed as required, and a resident whose care plan lacked interventions for incontinence and transfer assistance. Staff interviews and record reviews confirmed these deficiencies, which were not in line with facility policy and regulatory requirements.
A resident with severe cognitive impairment and total incontinence did not receive required incontinence care or ADL assistance over several hours, despite documented needs and observed signs of discomfort. Staff failed to perform incontinence checks or provide care during this period, and the care plan lacked instructions for a check and change program.
Three residents with varying cognitive and physical abilities did not receive adequate activity engagement, as care plans were not fully implemented, documentation of invitations and participation was lacking, and staff failed to coordinate to ensure residents were informed of and assisted to attend preferred activities.
A resident with severe contractures, cognitive impairment, and existing pressure ulcers was repeatedly observed without a pressure-relieving device between the knees. Staff used a foam wedge or a folded sheet, but not a dedicated device, and the wound care nurse was unaware of any such device being used. This failure to provide appropriate pressure ulcer prevention measures led to a deficiency.
Two residents did not receive their prescribed controlled medications for anxiety and pain due to delays in pharmacy delivery and failure by nursing staff to utilize available emergency medication supplies. Despite existing procedures and policies for reordering and accessing medications, staff did not ensure timely administration, resulting in missed doses for both residents.
Expired medications, including Pro-Stat Nutricia, blood glucose control solution, and extra-strength antacids, were found in a medication cart on the Left Wing. An LPN confirmed the items were expired, and interviews revealed that while staff are expected to check for expired drugs, there was no consistent system in place to ensure this was done, leading to the deficiency.
A resident with dysphagia and a physician's order for speech therapy did not receive a timely evaluation due to a breakdown in communication between nursing and the therapy department. The order for speech therapy was not relayed to the therapy team until the resident complained about her pureed diet, resulting in a delayed screening and evaluation.
A resident who was non-ambulatory and assessed as not at risk for wandering had their wander guard removed, but the EMR still contained an active order to check the device daily. Nursing staff continued to document completion of this task on the MAR, despite the device no longer being in use, resulting in inaccurate documentation of care provided.
A resident was prescribed doxycycline for an upper respiratory infection without documented evidence of an active infection, as required by facility policy. The infection control log lacked necessary details such as lab results and symptoms, and the Infection Preventionist had not reviewed lab or x-ray findings to confirm the need for antibiotics or their appropriateness.
Surveyors found that several resident rooms and main hall areas lacked proper ventilation due to non-functional bathroom fans and dirty vents, resulting in poor air circulation and noticeable odors. Maintenance staff and administration confirmed these issues, citing staffing shortages and incomplete maintenance records, with only monthly filter changes documented.
Deficient Food Safety and Sanitation Practices in Kitchen and Ice Handling
Penalty
Summary
The facility failed to ensure proper food safety and sanitation practices in the kitchen and food service areas. During observations, undated food items such as shredded lettuce and English peas were found in the walk-in cooler, and the Dietary Manager confirmed these items were not labeled or dated. The kitchen environment was noted to be unclean, with dust and grease accumulation on a portable air conditioning unit, vents, and behind cooking equipment. Ceiling tiles throughout the kitchen were discolored and stained, with one tile sagging above the vent hood. Additionally, temperature logs for the dish machine were incomplete, with no records for two consecutive days prior to dishwashing. The kitchen was also found to be excessively warm due to a non-functioning air conditioner, with a thermostat reading of 84 degrees, and a large fan used for cooling was covered in sticky dust. Maintenance issues, including the broken air conditioning, were not documented in the facility's maintenance request system. Further deficiencies were observed in the handling and storage of ice. An uncovered and visibly dirty ice scoop was found in a cracked and broken container on the ice chest cart. The Assistant Director of Nursing acknowledged the condition of the scoop and container, noting that the scoop should be covered and the container replaced. The Administrator later confirmed awareness of the issue and stated that new ice scoops and containers had been ordered. These deficiencies had the potential to affect all 77 residents receiving oral diets from the kitchen, as they could be exposed to foodborne illness due to improper food storage, unsanitary kitchen conditions, and inadequate ice handling practices.
Failure to Maintain Safe, Clean, and Sanitary Environment in Resident Rooms and Common Areas
Penalty
Summary
The facility failed to maintain a safe, functional, and sanitary environment in 16 of 47 resident rooms, the main dining room, and both the right and left wing day rooms. Observations revealed multiple deficiencies, including exposed holes in walls where electrical outlets were missing, jagged and peeling veneer on nightstands, loose and unsecured furniture, broken and crumbling tiles, and water-damaged flooring. In several rooms, there were also instances of mildew or black stains on walls and ceilings, missing toilet paper holders, plungers stored directly on the floor, and loose or wobbly toilets. Staff interviews confirmed that some of these issues had been present for weeks and that maintenance and housekeeping staff were not always aware of the problems until pointed out during the survey. Common areas such as the day rooms and main dining room were observed with scratched or peeling paint, stained and dirty walls, sticky countertops, and accumulations of dust, dirt, and cobwebs. Additional issues included broken tiles, missing trim, gaps in exit doors large enough for pests to enter, and a general buildup of grime and debris in corners and along baseboards. In several resident rooms, there were broken or missing light covers, unsecured or broken furniture, water leaks, and warped dressers. Some bathrooms had missing or broken fixtures, stained or dirty commode seats, and evidence of water damage that had not been cleaned or repaired. During the environmental tour, facility staff including the Administrator, DON, Maintenance Director Assistant, Housekeeping Director, and regional corporate staff confirmed the presence of these deficiencies. Staff acknowledged that some repairs and cleaning tasks had not been completed, and in some cases, they were unaware of the extent of the issues until the survey. The facility had recently been without a Maintenance Director, which contributed to delays in addressing maintenance and environmental concerns.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program as required by its own policy, which states that the building should be kept free of insects and rodents through an ongoing pest control program. Record review and interviews revealed that several residents reported the presence of roaches, water bugs, gnats, and other pests in their rooms and common areas, such as bathrooms and shower rooms. Resident Council Minutes documented multiple complaints about pest infestations, with the facility's stated response being to schedule monthly exterminator visits. However, pest control logs showed inconsistent service, with significant gaps between treatments and no evidence of monthly extermination as promised. Multiple residents, most of whom had intact cognition as indicated by their BIMS scores, described frequent sightings of pests in their rooms and throughout the facility. Some residents attributed the pest issues to factors such as trash bins being kept in hallways and food being left on the floor. One resident reported being so disturbed by the pests that a family member had to spray the room for bugs to allow her to sleep. The facility's pest control records confirmed pest activity during service visits, but did not demonstrate a consistent or effective approach to pest management, leading to ongoing resident complaints and observations of pests in living areas.
Failure to Facilitate Residents' Right to Vote
Penalty
Summary
The facility failed to ensure that three residents were able to exercise their right to vote in elections through absentee ballots or other authorized methods, as required by their own policy and federal regulations. The policy stated that residents should be encouraged to participate in community activities, including voting, and that transportation may be arranged through the Activity or Social Services Departments. However, review of facility records and interviews revealed that residents who expressed a desire to vote were not provided with adequate assistance or information to do so. One resident, with moderate cognitive impairment, stated that they wanted to vote but were not asked or informed about how to participate. Another resident, who was cognitively intact, was told they could not vote because their identification was expired and from another state, and no assistance was provided to obtain a valid ID. A third resident, also cognitively intact, had identification and expressed interest in voting upon admission, but was not asked about voting or provided with the opportunity, which the resident linked to feelings of depression. Interviews with facility staff revealed a lack of follow-up and communication regarding residents' interest in voting. The Social Services Director and Activities Director both acknowledged gaps in the process, including not revisiting new admissions to assess voting interest and not assisting residents in obtaining necessary identification or absentee ballots. Transportation issues and lack of coordination with families further contributed to the residents' inability to exercise their voting rights.
Failure to Invite Resident to Participate in Care Plan Meetings
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident was invited to participate in the development and implementation of her person-centered care plan. The resident, who was admitted with diagnoses including dementia, psychotic disturbance, mood disturbance, and anxiety, was found to be cognitively intact based on a BIMS score of 14 out of 15. Review of the care plan and associated documentation revealed no evidence that the resident had been invited to or participated in any care plan meetings, despite multiple revisions to her care plan over time. During interviews, the resident stated she was unaware of any care meetings involving staff from various departments and confirmed she had not attended such meetings, only participating in resident council meetings. The Social Services Designee (SSD), responsible for scheduling care plan meetings, indicated that family members were notified of meeting times and that sign-in sheets were maintained. However, the SSD was unable to provide documentation or sign-in sheets to demonstrate that the resident had been invited to or participated in her care plan meetings, even after multiple requests during the survey.
Failure to Honor Resident's Advance Directive Due to Inaccurate Code Status Documentation
Penalty
Summary
The facility failed to ensure that a resident's advance directive and code status were accurately reflected and communicated among staff and in the electronic medical record (EMR). Although the resident had a completed and signed Do Not Resuscitate (DNR) order and was admitted to hospice care, the EMR, care plan, physician's orders, and code status book all indicated the resident was a full code, meaning all resuscitative measures would be taken in the event of a medical emergency. Multiple staff members, including LPNs, the MDS Coordinator, and the DON, all referenced the EMR and code status book, confirming that they would initiate CPR based on the information available, which was inconsistent with the resident's documented wishes and hospice status. Interviews with hospice nurses revealed that the resident had been DNR since admission to hospice, and there were signed DNR documents present. However, the facility's process for verifying and updating code status failed, as staff relied on outdated or incorrect information in the EMR and code status book. This discrepancy placed the resident at risk of not having her end-of-life wishes honored, as staff would have performed resuscitative measures contrary to the resident's documented DNR status.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed all identified needs for three residents. One resident, who was cognitively intact but had severe visual impairment, expressed a strong preference for specific activities such as listening to music, keeping up with the news, participating in group activities, and going outside. Despite these preferences being documented in the MDS, the care plan did not reflect them, and the resident was observed sitting in her room with minimal activity involvement. Additionally, this resident had an active order for TED hose due to lower extremity edema, which was not addressed in the care plan, and the resident reported not wearing the hose since admission, despite ongoing documentation of edema in weekly assessments. Another resident with severe cognitive impairment, hemiplegia, and contractures was dependent on staff for all activities of daily living and had pressure ulcers. Observations revealed that this resident was not consistently provided with pressure-relieving devices between the knees, and there was no care plan specifically addressing contractures or pressure relief. Staff interviews confirmed the absence of such a care plan, despite the resident's significant physical limitations and risk factors. A third resident, who was severely cognitively impaired and dependent on staff for mobility and ADLs, had documented preferences for a variety of activities, including religious services, music, and group events. However, the care plan did not address the resident's activity needs or participation, even though assessments indicated these were very important to the resident. Staff interviews confirmed that an activities care plan should have been in place but was not developed.
Failure to Develop and Revise Comprehensive Care Plans for Multiple Residents
Penalty
Summary
The facility failed to ensure that care plans were developed, reviewed, and revised in accordance with regulatory requirements for several residents. For one resident with a history of stroke and severe cognitive impairment, the care plan included an intervention for the use of heel protectors to address skin impairment and pressure injury risk. However, observations revealed that heel protectors were not in use while the resident was in bed, and there was no current physician's order for them. Staff interviews indicated a lack of awareness regarding the intervention, and the care plan was subsequently revised to remove the heel protectors without clear documentation of the clinical decision-making process. Another resident, admitted with dementia and other neurological diagnoses, had care plan documentation that did not reflect timely quarterly care plan conferences. The care plan history showed only two completed care plans despite the resident's ongoing stay, and the Social Service Director was unable to explain the lack of regular care plan reviews. This failure to conduct and document regular care plan conferences limited the facility's ability to assess, review, and revise care plans as needed. Additionally, a resident with multiple physical disabilities and incontinence did not have a care plan that addressed incontinence management or specific transfer assistance needs. Staff interviews confirmed the resident was incontinent and required frequent checks and changes, but this was not reflected in the care plan. Similarly, the care plan did not specify the resident's transfer needs, despite staff routinely using two-person transfers and gait belts. Facility policies required care plans to be updated with such information, but this was not done, resulting in incomplete care planning for the resident.
Failure to Provide Incontinence Care and ADL Assistance
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, muscle weakness, above-the-knee amputation, aphasia, and deafness did not receive appropriate assistance with activities of daily living (ADLs), specifically incontinence care. The resident was documented as always incontinent and required a check and change program, as indicated in the Bladder Incontinence Evaluation. However, the resident's care plan did not address incontinence or the need for a check and change program, and the Kardex lacked specific instructions regarding incontinence care. Direct observation revealed that the resident remained in a geriatric chair in the day room for several hours without any incontinence checks by staff. The resident was moved between locations by staff and participated in activities, but at no point during the observed period was incontinence care provided. The resident exhibited signs of discomfort, such as yelling out and squirming in the chair, but staff did not respond with incontinence checks or care until the resident was eventually taken to their room.
Failure to Provide Sufficient Activity Engagement for Multiple Residents
Penalty
Summary
The facility failed to provide sufficient activity engagement to meet the needs of three residents, as evidenced by observations, interviews, and record reviews. One resident, who was cognitively intact but severely visually impaired, expressed that she could not see and spent her time sitting and listening to the TV. Her care plan included interventions such as inviting her to scheduled activities and providing assistance, but there was no documentation of invitations or participation, and she was observed sitting in her room without engagement throughout the survey period. Another resident, who was severely cognitively impaired, deaf, and nonspeaking, had documented preferences for a variety of activities, including religious services, arts and crafts, and group events. Despite these preferences and family input indicating a need for more engagement, the resident's care plan did not address activity needs, and participation records showed only sporadic involvement in group activities like Bingo. Observations revealed long periods where the resident was left in a geriatric chair without engagement, and the Activities Director confirmed that one-to-one visits, which were indicated as needed, had not been implemented. A third resident, who was cognitively intact but dependent on staff for mobility and had a history of depression and stroke, also experienced insufficient activity engagement. Although his care plan called for one-to-one visits and a program of activities tailored to his interests, records showed minimal participation, and he reported not being informed about or assisted to attend activities he enjoyed, such as Bingo. Staff interviews revealed a lack of coordination between the Activities Director and nursing staff, resulting in the resident not being invited or assisted to attend group activities, and no one-to-one visits were provided despite being care planned.
Failure to Provide Pressure-Relieving Device for Resident with Contractures
Penalty
Summary
A resident with a history of severe cognitive impairment, hemiplegia, hemiparesis, and contractures was not consistently provided with a pressure-relieving device between the knees, despite being dependent on staff for all functional abilities and having existing pressure ulcers. The resident was observed on multiple occasions with contracted legs drawn up tightly toward the buttocks and knees together, without any pressure-relieving device in place between the knees. During care observations, staff were seen positioning the resident with a foam wedge under the knee or a folded flat sheet between the knees, but not with a dedicated pressure-relieving device. The wound care nurse confirmed that she was not aware of any pressure-relieving device being used between the resident's knees. These findings indicate that the facility failed to ensure appropriate pressure ulcer prevention measures for this resident.
Failure to Provide Timely Controlled Medications Due to Pharmacy and Staff Oversight
Penalty
Summary
The facility failed to provide necessary pharmaceutical services to meet the needs of two residents who required controlled medications for anxiety and pain management. One resident, admitted with diagnoses including seizures, aphasia, and deaf non-speaking, had a severely impaired cognitive status and was prescribed lorazepam for anxiety. Despite having a physician's order for lorazepam, multiple doses were not administered over several days due to delays in obtaining the medication from the pharmacy. Documentation in the electronic medical record indicated repeated notes of waiting for pharmacy delivery, and nursing staff confirmed the resident did not refuse the medication. Although lorazepam was available in the facility's emergency medication supply, it was not utilized to prevent missed doses. Another resident, admitted with a history of joint replacement and osteoarthritis, was prescribed tramadol for pain management. This resident, who was cognitively intact, reported to nursing staff that he had been without his pain medication for over two days. Nursing staff confirmed the medication had not been delivered and had not been administered as ordered. The facility had a process in place to access emergency medication supplies (Pyxis machine) in such situations, but this process was not followed, resulting in the resident not receiving pain medication as needed. Interviews with nursing staff and facility administration revealed a lack of awareness and follow-through regarding the availability and administration of these controlled medications. Staff acknowledged that procedures existed to obtain medications from emergency supplies when routine deliveries were delayed, but these procedures were not implemented. The facility's own policy required staff to check for pharmacy communications and contact the pharmacy for missing medications, but this was not effectively carried out, leading to missed doses for both residents.
Expired Medications Found in Medication Cart Due to Lack of Systematic Checks
Penalty
Summary
Surveyors observed that the facility failed to remove expired medications from one of two medication carts located on the Left Wing. During an inspection of the medication cart at the nurses' station, an open bottle of Pro-Stat Nutricia with an expiration date of 5/16/2025, an unopened box of blood glucose control solution with an expiration date of 12/7/2024, and an open bottle of extra-strength antacids with an expiration date of 3/2025 were found. The LPN present confirmed that all these items were expired. Interviews with the LPN and the Administrator revealed that nursing staff are expected to check medication carts for expired medications, but there was no established system in place for ensuring this task is consistently performed. The facility's policies require that expired, discontinued, or deteriorated drugs be removed and either destroyed or returned to the pharmacy, but these procedures were not followed, resulting in expired medications being accessible in the medication cart.
Failure to Provide Timely Speech Therapy Evaluation for Swallowing Disorder
Penalty
Summary
A deficiency occurred when a resident admitted with diagnoses including dysphagia, anxiety, depression, and failure to thrive did not receive timely speech therapy services as ordered to address a swallowing problem. The resident was admitted with a physician's order for a speech therapist to evaluate and treat as indicated, as well as an order for a pureed texture diet. Despite these orders, the speech therapy evaluation was not initiated promptly. The facility's policy required evaluations to be initiated within a reasonable time following receipt of a physician's order, but the order for speech therapy, entered on 5/28/2025, was not communicated to the therapy department until 6/9/2025. As a result, the resident did not receive a speech therapy screening until 6/11/2025. The delay was due to a breakdown in communication between nursing and the therapy department. Nursing staff were responsible for entering orders into the electronic medical record and communicating new orders to therapy via a screening request form. However, the Rehab Director and the speech therapist were unaware of the order until the resident expressed dissatisfaction with her food texture, prompting nursing to submit the screening request. During this period, the resident reported frustration with the pureed diet, had unclear speech, and exhibited drooling with loss of saliva control. Staff interviews confirmed that the communication process failed, resulting in the resident not receiving the ordered evaluation in a timely manner.
Inaccurate Documentation of Wander Guard Use for Non-Ambulatory Resident
Penalty
Summary
The facility failed to ensure that the clinical record accurately reflected the care provided to a resident regarding the use of a wander guard device. The resident, who had multiple diagnoses including muscle weakness, seizures, aphasia, and was non-ambulatory and dependent on staff for all mobility and activities of daily living, was assessed as not being at risk for wandering or elopement. The resident's assessment documented that the wander guard was removed due to his inability to self-propel and lack of wandering behaviors. The care plan did not address wandering or elopement risk. Despite the removal of the wander guard, the electronic medical record (EMR) still contained an active physician's order to check the function of the wander guard daily, and nursing staff continued to initial on the Medication Administration Record (MAR) that this was being completed. Staff interviews confirmed that the resident did not have a wander guard and that the order should have been discontinued, but staff were unaware that the order remained active and continued to document its completion inaccurately. This resulted in a misrepresentation of the care being provided, contrary to facility policy requiring accurate and factual documentation.
Failure to Ensure Appropriate Antibiotic Use Without Confirmed Infection
Penalty
Summary
The facility failed to ensure that antibiotics were not used without the presence of a diagnosed infection for one of three residents reviewed for antibiotic stewardship. According to the facility's policy, the Infection Control Coordinator or designee is required to complete a surveillance document using the McGeer criteria to confirm evidence of infection before antibiotics are administered, and to contact the physician if the criteria are not met. For one resident, documentation showed that doxycycline was prescribed for an upper respiratory infection, but the infection control log lacked information on the organism, x-ray results, lab or culture results, and did not include a section for symptoms or whether the infection met the required criteria. The resident's chest x-ray indicated no active disease or evidence of pneumonia, and there was no documentation of communication with the physician regarding the continued use of antibiotics in the absence of an active infection. The Infection Preventionist (IP) reported that she had not reviewed lab or x-ray results as part of the antibiotic stewardship program and relied on nurses' notes to determine the effectiveness of antibiotics. The IP also stated she did not have a process to determine if the prescribed antibiotic was appropriate based on organism susceptibility, as she did not have access to lab results. The IP confirmed that she had not reviewed the resident's use of doxycycline to determine if the infection met criteria or if the antibiotic was appropriate, and had not seen the relevant chest x-ray results.
Failure to Maintain Adequate Ventilation and Environmental Hygiene
Penalty
Summary
Surveyors observed that the facility failed to maintain proper ventilation in six resident rooms and the main hall, resulting in inadequate air circulation and environmental hygiene. Specifically, bathroom ventilation fans were found to be non-operational in several rooms, and shared bathrooms had a heavy urine odor with exhaust vents that did not function, as confirmed by maintenance staff using tissue paper tests. Additionally, hallway ceiling vents and grates were covered in excessive dirt and debris, including blackened substances and thick, furry matter. These issues were confirmed during facility tours with the Maintenance Director Assistant, Housekeeping Director, Administrator, DON, and corporate staff. Interviews with facility staff revealed that although air filters were changed monthly, other aspects of ventilation maintenance, such as cleaning vents and ensuring fan operation, were not adequately addressed. The Administrator noted staffing shortages in the maintenance department, which contributed to the inability to keep up with required maintenance tasks. Maintenance records reviewed for the past year only documented filter changes, with no further details on other ventilation system upkeep.
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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