Bell Minor Home, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Gainesville, Georgia.
- Location
- 2200 Old Hamilton Place Ne, Gainesville, Georgia 30507
- CMS Provider Number
- 115020
- Inspections on file
- 19
- Latest survey
- March 30, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Bell Minor Home, The during CMS and state inspections, most recent first.
Two residents experienced significant changes in condition, including worsening edema, absent pedal pulses, and a rapidly progressing diabetic foot ulcer, but their medical providers and families were not notified in a timely manner as required by facility policy. One resident died after developing gangrene and sepsis, while another required a below-the-knee amputation due to gangrene. Documentation and staff interviews confirmed that notifications were not made as expected, resulting in actual harm and death.
Multiple residents experienced serious harm due to the facility's failure to prevent abuse and neglect. One resident died after staff failed to notify a physician and denied a family's request for hospital transfer following a significant change in condition. Another resident suffered a below-the-knee amputation after delayed wound care and lack of recommended interventions for a diabetic ulcer. Additionally, a resident with a history of aggressive behavior physically abused her roommate by wrapping a call light cord around her neck, despite prior incidents and insufficient preventive measures.
Nursing staff did not notify the medical provider when a resident experienced worsening edema, bruising, and absent pedal pulses, despite facility policy requiring such notification. The lack of timely communication and intervention led to the resident's condition deteriorating, culminating in an emergency hospital transfer and subsequent death. Interviews confirmed that providers were not informed of critical changes, resulting in Immediate Jeopardy.
Three residents developed or experienced worsening pressure ulcers due to the facility's failure to implement preventive interventions, timely wound assessments, and physician-ordered treatments. In two cases, significant delays in care and lack of documentation led to the progression of ulcers, with one resident's wound contributing to death and another requiring surgical debridement and hospitalization for infection. The facility did not follow its own protocols for wound care, documentation, and use of pressure-reducing devices, resulting in Immediate Jeopardy.
Facility administration failed to ensure that nursing staff identified, assessed, and reported changes in residents' skin conditions, resulting in actual harm and death. Additionally, the facility did not protect a resident from repeated abuse by another resident, despite documented incidents. The DON and Administrator acknowledged that staff did not follow established protocols, and the facility was cited for substandard quality of care, including failure to prevent and treat pressure ulcers.
The facility did not ensure that the interval between dinner and breakfast was within the required 14 hours, resulting in a 15-hour gap for most residents. Some residents reported hunger and dissatisfaction with the available evening snacks, and staff confirmed that the issue had been raised in resident council meetings without group approval for the extended interval.
Surveyors found that staff failed to follow food safety and hand hygiene protocols in the kitchen, including improper storage of clean cups with pooled water, inconsistent labeling of leftovers, and dietary aides handling ready-to-eat foods with gloved hands while also touching non-food items without changing gloves or washing hands. These actions affected nearly all residents except those on tube feeding.
Surveyors found that the dumpster area was not maintained in a sanitary manner, with garbage and refuse—including used gloves, masks, and food containers—strewn around the dumpsters and along the parking lot edge for several days. The dumpster door was left open, and a large garbage bag was hanging outside the container. Staff interviews revealed confusion over responsibility for cleaning the area, and the unsanitary conditions persisted, potentially affecting all residents.
The facility's Arbitration Agreement, signed by all current residents at admission, did not include a clause for selecting a mutually convenient venue for arbitration. The Administrator confirmed the absence of this provision and that no location criteria were present in the agreement.
The facility did not ensure that physicians responded in a timely manner to pharmacist recommendations made during monthly medication regimen reviews for several residents with cognitive impairment and psychiatric diagnoses. Documentation and interviews showed missing or delayed physician responses to recommendations for dose reductions and medication changes, with facility staff and the pharmacist confirming ongoing issues in obtaining and documenting provider actions.
Multiple residents reported that meals were consistently served cold, lacked flavor, and were missing condiments such as salt, pepper, and sugar. Surveyors observed food and beverages left at room temperature, meal service times exceeding policy limits, and the use of leftovers instead of freshly prepared food. Staff interviews confirmed that condiments were not routinely provided and that leftovers were reused for subsequent meals, leading to ongoing complaints about food quality.
A resident with Alzheimer's disease and other conditions was admitted to hospice, but the facility did not complete a Significant Change MDS Assessment as required. Staff interviews and record reviews confirmed that the assessment was not performed after the initiation of hospice services, despite facility policy and federal guidelines.
Quarterly MDS assessments were not completed within the required 92-day timeframe for three residents, including individuals with chronic conditions such as COPD, Alzheimer's disease, myasthenia gravis, heart failure, and atrial fibrillation. Staff interviews revealed that while the MDS Coordinator used the EMR system to track assessments, overdue assessments were confirmed, and there was a lack of tracking by the Regional Remote MDS nurse.
Two residents did not have their pressure ulcers and diabetic foot ulcers accurately coded on MDS assessments, despite clear documentation in medical records and ongoing wound care. The MDS Coordinator, DON, and Regional Remote MDS nurse confirmed that the assessments should have reflected the actual wound status and treatments, but the required accuracy and validation were not met, resulting in incorrect and incomplete MDS documentation.
A resident with diabetes and Alzheimer's developed a diabetic foot ulcer, but the facility did not update the care plan to include the ulcer or recommended interventions such as turning, repositioning, and use of heel boots. Although wound care and staff education were documented, these actions were not reflected in the official care plan until after the resident was hospitalized with gangrene.
A resident with severe cognitive impairment and incontinence did not consistently receive scheduled showers as required by facility policy. Staff interviews and documentation review revealed missed showers over several months, with staff citing resistance to care and staffing shortages as contributing factors. The resident was observed with greasy hair and saturated clothing, indicating a lack of proper hygiene care.
A resident with significant mobility limitations and a need for bed rails did not have required quarterly safety assessments documented, as mandated by facility policy. Staff interviews and record reviews confirmed that the electronic system did not prompt for these assessments, and only outdated paper assessments were found. This lapse was acknowledged by the DON and RDCO, with no current assessments completed for the resident.
Three residents did not receive prescribed antibiotics and pain medications as ordered due to delays in pharmacy delivery, lack of medication in contingency supplies, and issues with medication reordering and access. Staff and nurse interviews confirmed ongoing problems with timely medication availability, resulting in missed doses for residents with serious medical conditions.
Two residents experienced significant medication errors when critical medications, including cardiac drugs and insulin, were not administered as ordered due to pharmacy delivery delays, lack of access to emergency medication supplies, and expired stock. Staff identified the issues but did not consistently utilize available resources or follow facility policy, resulting in missed doses and elevated blood sugar for one resident.
The facility did not ensure proper infection control practices for two residents, including failure to use required PPE during high-contact care for a resident with a gastrostomy tube and lack of PPE availability outside the room for a resident with C. difficile. Staff demonstrated confusion about which precautions applied to which residents, and signage and PPE placement did not align with facility policy, resulting in lapses in infection prevention.
The facility failed to lock cabinets in shower rooms on A and B Halls, which contained hazardous items like razors and cleaning supplies. Observations confirmed the cabinets were unlocked, with one having a broken lock and the other lacking a lock entirely. This posed a potential risk to two residents known to wander the facility. Staff interviews revealed a lack of awareness about the issue, and the facility's policy on maintaining shower rooms was not provided.
Failure to Notify Providers and Family of Change in Condition Resulting in Death and Harm
Penalty
Summary
The facility failed to ensure timely notification of changes in condition to medical providers and family members for two residents, resulting in death for one and actual harm for another. For one resident with multiple diagnoses including congestive heart failure, diabetes, and deep vein thrombosis, there were repeated instances where significant changes such as worsening edema, bruising, and absent pedal pulses were documented in the medical record, but not communicated to the resident's medical provider. The family was also not informed of the resident's deteriorating condition over a period of several days, despite their concerns and requests for hospital transfer, which were denied by the facility. The resident ultimately developed severe complications, including gangrene and sepsis, and died after being transferred to the hospital. In the second case, a resident with diabetes and Alzheimer's disease developed a diabetic foot ulcer that was treated in the facility. The wound increased in size and severity, with new discoloration and necrosis observed by nursing staff. However, the wound care practitioner was not notified of these changes until the following day, when the resident was transferred to the hospital. The family was not informed of the existence or progression of the wound until the resident was sent to the emergency room, at which point the resident required a below-the-knee amputation due to gangrene and necrotizing cellulitis. The facility's own policy required notification of the physician and family within 24 hours of a significant change in a resident's condition, but this was not followed in either case. Interviews with facility staff, including the DON and medical providers, confirmed that the expectation was for prompt communication of such changes. Documentation in the electronic medical record and staff statements further supported that these notifications did not occur as required, directly contributing to the negative outcomes for both residents.
Failure to Prevent Abuse and Neglect Resulting in Harm and Death
Penalty
Summary
The facility failed to protect residents from abuse and neglect, resulting in actual harm and death for several individuals. In one case, a resident with multiple serious medical conditions, including angioneurotic edema, CHF, DVT, and diabetes, developed a fluid-filled blister and later had unpalpable pedal pulses. Despite the family's request for hospital transfer and clear signs of a change in condition, the nurse practitioner denied the transfer, and nursing staff did not notify the physician. The resident's condition worsened, and she was eventually transferred to the hospital, where she died from complications related to the facility's failure to notify the physician and delay in treatment. Another resident with diabetes and Alzheimer's disease developed a diabetic ulcer on the right foot. Nursing staff identified the wound but delayed notifying the wound care provider, and there was a lack of timely assessment and intervention. The wound worsened significantly, with documentation showing an increase in size and necrotic tissue, but recommended interventions such as heel boots and frequent repositioning were not implemented. The resident was eventually transferred to the hospital with gangrene and underwent a below-the-knee amputation. The care plan was not updated to reflect the wound until after the amputation. A third incident involved a resident with a history of behavioral disturbances and aggression toward roommates. Despite multiple documented incidents of verbal and physical aggression, including hiding call bells, interfering with roommates' care, and escalating behaviors, the facility failed to implement effective interventions to prevent further abuse. Ultimately, this resident physically abused her roommate by wrapping a call light cord around her neck and tying it to the bedrail. Staff and social services were aware of the ongoing behaviors, but the interventions were insufficient to prevent harm. The facility's noncompliance with requirements of participation resulted in serious injury, harm, and death to residents.
Failure to Notify Provider of Resident's Change in Condition Resulting in Immediate Jeopardy
Penalty
Summary
The facility failed to ensure that nursing staff used their clinical skills and judgment to identify and notify a resident's medical provider of a significant change in condition. Specifically, a resident with multiple diagnoses, including angioneurotic edema, congestive heart failure, deep vein thrombosis, and diabetes, experienced worsening edema, a bruised area on the left foot, and eventually unpalpable pedal pulses. Despite these changes, there was no documented evidence that the nursing staff notified the resident's medical provider of the worsening edema, bruising, or absence of pedal pulses prior to the provider's visit. The facility's policy required nurses to notify the provider of significant changes in a resident's condition, but this was not followed in this case. Further review revealed that the nursing staff documented the absence of palpable pedal pulses on two occasions but did not implement any nursing interventions or notify the physician. When a fluid-filled blister was observed on the resident's calf, the family requested a transfer to the emergency department, but this request was denied by the nurse practitioner, who instead ordered antibiotics for cellulitis. The resident's condition continued to deteriorate, with discolored areas and unpalpable pulses noted, and an ankle brachial index was ordered. Eventually, after further decline and the development of gangrene, the decision was made to transfer the resident to the hospital, where she died hours after arrival due to complications from the worsening skin condition. Interviews with facility staff, including the DON, nurse practitioners, and medical directors, confirmed that the expectation was for nursing staff to notify providers of significant changes in condition, such as absent pedal pulses or worsening edema. However, the providers were not made aware of these changes in a timely manner, which delayed further assessment and aggressive treatment. The facility's failure to follow its own policy and ensure timely communication of the resident's change in condition resulted in an Immediate Jeopardy situation.
Failure to Prevent and Treat Pressure Ulcers Resulting in Immediate Jeopardy
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for three sampled residents. For two residents, significant pressure ulcers developed and worsened due to a lack of preventive interventions, delayed treatment orders, and insufficient wound assessments. In one case, a resident did not have preventive measures in place before a sacral pressure ulcer was identified, and there were no treatment orders for nine days after the ulcer was first observed. The first assessment with measurements and description of the wound was not completed until 23 days after the ulcer was noted. The wound progressed to a stage 4 ulcer, became larger and deeper, and was associated with infection. Recommendations for protective boots and a specialty pressure relief mattress were not implemented, and there was a 21-day gap without any wound assessment or measurements by either the wound care provider or facility nursing staff. The resident's pressure ulcer continued to deteriorate, and the physician indicated that the ulcer likely contributed to the resident's death. Another resident developed a new open area on the sacrum, but after returning from a hospital stay, there were no evaluations of the wound for several days, and treatment orders were not obtained until later. Wound assessments by the contracted wound company did not document the sacral wound, and the wound was found to be unstageable with 100% necrotic tissue, requiring surgical debridement. The resident was hospitalized for an infected sacral decubitus ulcer and discharged on intravenous antibiotics. The lack of preventive interventions, timely assessments, and treatment per physician orders placed the resident at risk for further infection and worsening of the pressure ulcer. The facility's own policies required weekly documentation and assessment of wounds, use of pressure-reducing devices, and implementation of preventive protocols such as turning and repositioning. However, these protocols were not followed. There were multiple instances where wound care treatments were not documented as completed, and staff interviews confirmed gaps in care, lack of documentation, and failure to implement recommended interventions. The facility was cited for Immediate Jeopardy due to noncompliance that caused or had the likelihood to cause serious injury, harm, impairment, or death to residents.
Failure to Ensure Timely Assessment, Reporting, and Protection of Residents
Penalty
Summary
Facility administration failed to ensure effective use of resources to maintain residents' highest physical well-being, as evidenced by multiple failures in nursing care and oversight. Specifically, the Administrator and DON did not identify or address failures by nursing and other staff, resulting in actual harm and death among residents. The administration did not ensure that physicians or other medical providers were notified when two residents experienced changes in their skin conditions, nor did they ensure that staff identified, assessed, or reported these changes. Nursing staff neglected to recognize or report the worsening of skin conditions, and the facility failed to protect a resident from abuse by another resident, despite documentation of repeated abusive incidents. The DON confirmed that nurses had received training on change in condition policies, and that the ADON was responsible for ongoing staff education. However, despite these measures, nurses did not follow established protocols for alert charting, provider notification, assessment, or documentation when changes in condition occurred. The Administrator and DON both acknowledged that these failures were not in accordance with facility policy. The facility was cited for substandard quality of care, including failure to prevent and treat pressure ulcers, and was found to be in Immediate Jeopardy due to noncompliance that caused or had the likelihood to cause serious injury, harm, impairment, or death to residents.
Failure to Maintain Required Interval Between Dinner and Breakfast
Penalty
Summary
The facility failed to ensure that the time between the evening meal and breakfast the following day did not exceed 14 hours for 99 out of 101 residents, as required. Scheduled mealtimes resulted in a 15-hour gap between dinner and breakfast, and this gap was sometimes extended further due to late meal service. The facility did not provide a substantial evening snack to compensate for the extended interval, and the resident group had not approved the 15-hour gap. The facility's Menu Planning policy did not specify maximum allowable time between meals, and the mealtimes document confirmed the 15-hour interval. Observations and interviews revealed that residents experienced hunger due to the long gap between dinner and breakfast. Some residents reported not receiving enough food at dinner and not being offered suitable snacks in the evening, with available snacks limited to chips and cookies, which were not acceptable to all residents. Staff interviews confirmed that the issue of late meals and the long gap between dinner and breakfast had been raised in resident council meetings, but no approval for the extended interval had been obtained. The Dietary Manager and Registered Dietitian acknowledged awareness of the 14-hour requirement but confirmed that the current schedule did not comply.
Failure to Follow Food Safety and Hand Hygiene Practices in Kitchen
Penalty
Summary
The facility failed to maintain proper food service practices in the kitchen, resulting in potential risks for foodborne illness for 99 out of 101 residents. During multiple inspections, surveyors observed stacks of plastic cups stored as clean but with pooled water and condensation between them, indicating that the cups were not properly air dried before being stacked. The Dietary Manager confirmed that cups should be air dried to prevent bacterial growth. Additionally, leftover foods in the refrigerator were inconsistently labeled, making it unclear whether the dates indicated when the food was stored or when it should be discarded. The facility's policy required both the date of storage and the use-by date to be clearly labeled, but this was not consistently followed. During meal service observations, two dietary aides were seen handling ready-to-eat foods such as hoagie buns and potato chips with gloved hands, while also touching various non-food items like utensil handles, tray cards, plates, counters, and refrigerator handles without changing gloves or performing hand hygiene. Both the Dietary Manager and Registered Dietitian confirmed that gloves are intended for single use and should not be used to touch multiple surfaces. The aides acknowledged they had not considered the risk of cross-contamination from touching multiple items with the same gloves. These actions were in direct violation of the facility's hand washing and food labeling policies.
Improper Disposal and Maintenance of Dumpster Area
Penalty
Summary
The facility failed to maintain the dumpster area in a sanitary condition, as required by its Waste Disposal policy, which states that all garbage should be disposed of daily and the surrounding area kept clean. Over the course of three days, surveyors observed garbage strewn around the dumpsters and along the edge of the parking lot, including items such as cigarette butts, plastic food containers, cardboard, used latex gloves, wipes, surgical masks, toothbrushes, soda bottles, straws, cigarette boxes, paper, and medication cups. The side door to the regular garbage dumpster was left open, and a large garbage bag was stuck in the lid and hanging outside the dumpster. No staff were observed disposing of garbage during these times. Interviews with facility staff revealed confusion regarding responsibility for maintaining the cleanliness of the dumpster area. The Dietary Manager stated that maintenance was responsible for cleaning the area, while the Maintenance Director indicated that dietary and housekeeping staff should maintain the area when disposing of garbage, with maintenance responsible for a weekly cleanup. The Maintenance Director acknowledged missing the scheduled cleaning for that week and confirmed the presence of garbage and the bag hanging outside the dumpster. The unsanitary conditions persisted for several days, affecting the environment for all residents at the facility.
Arbitration Agreement Lacks Mutually Convenient Venue Clause
Penalty
Summary
The facility failed to ensure that the Arbitration Agreement presented to residents and their representatives at admission included a clause specifying that the venue for arbitration would be mutually convenient and agreeable to both parties. Review of the undated Arbitration Agreement revealed the absence of any provision for selecting a mutually convenient venue or any location criteria. According to the Administrator, all 101 current residents had signed this agreement upon admission, and no arbitrations had been conducted since 2019. The Administrator confirmed during interviews that the agreement lacked the required clause, and the facility did not provide an arbitration agreement policy when requested by surveyors.
Failure to Ensure Timely Physician Response to Pharmacist Medication Review Recommendations
Penalty
Summary
The facility failed to ensure timely physician responses to pharmacist recommendations made during monthly medication regimen reviews for four out of five residents reviewed for unnecessary medications. According to the facility's policy, pharmacist recommendations should be acted upon within 30 days, and physicians are required to document their acceptance or rejection of these recommendations, including the rationale for any rejections. However, documentation and interviews revealed that physician responses were missing or significantly delayed for multiple residents, and in some cases, there was no evidence that recommendations were reviewed or addressed at all. For one resident with severe cognitive impairment and multiple psychiatric diagnoses, there were no documented pharmacist recommendations or physician responses regarding antidepressant and antipsychotic medications for several months. Another resident with dementia and psychotic disturbance had pharmacist recommendations for medication dose evaluation and PRN medication duration, but the responses were not provided until five months later, and one recommendation was not fully addressed. A third resident with moderate cognitive impairment and multiple psychotropic medications had several pharmacist recommendations for dose reductions and medication changes, but there was no documentation of physician responses. The fourth resident, admitted with dementia and psychotic disturbance, had a pharmacist recommendation for a dose reduction of an antipsychotic, but there was no physician response documented, and the medication regimen remained unchanged. Interviews with the DON, pharmacist, and regional clinical leadership confirmed ongoing issues with obtaining timely physician responses to pharmacist recommendations. The outgoing medical director was specifically identified as not returning responses, and the facility was unable to locate required documentation in the electronic medical record for the affected residents. The pharmacist reported routinely resubmitting recommendations due to lack of provider response, and facility leadership acknowledged the deficiency in following up on and documenting physician actions regarding pharmacy recommendations.
Failure to Provide Palatable and Properly Tempered Food and Drink
Penalty
Summary
The facility failed to ensure that food and drink served to residents was palatable, attractive, and at a safe and appetizing temperature, as required by their own Test Tray policy. Multiple residents with intact cognition reported that meals were consistently served cold or not hot, lacked flavor, and that condiments such as salt, pepper, sugar, and sugar substitute were not provided as indicated on the menu. Residents also reported that leftovers were routinely served instead of freshly prepared food, and these concerns were repeatedly documented in resident council meeting minutes over several months. Direct observations by surveyors confirmed that food and beverages were left sitting at room temperature for extended periods, and that meal service times exceeded the facility's policy of serving trays within 20 minutes of assembly. For example, one meal cart took 38 minutes from loading to final service, resulting in food temperatures below policy standards. Test trays evaluated by the Dietary Manager and surveyor showed hot foods served at temperatures as low as 95°F, well below the required 130°F-150°F, and cold foods not meeting the required cold temperature standards. Additionally, condiments were not present on tray lines or dining tables, and staff did not offer them to residents during meal service. Interviews with dietary staff, the Dietary Manager, and the Registered Dietitian revealed that leftovers, including scrambled eggs and pureed foods, were routinely reused for subsequent meals, contrary to best practices for food palatability. The Registered Dietitian confirmed that such practices should not occur and that food should be served hot and with appropriate condiments. The Social Worker and Resident Council minutes further corroborated ongoing resident complaints about cold and unpalatable food, indicating a persistent and unaddressed issue with the facility's food service practices.
Failure to Complete Significant Change MDS Assessment After Hospice Initiation
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) Assessment for a resident after the initiation of hospice services, as required by federal regulations and the facility's own policy. The resident, who had diagnoses including Alzheimer's disease, atrioventricular block, and hypertension, was admitted to hospice services. Despite this significant change in condition, a review of the electronic medical record and MDS assessments revealed that a Significant Change Assessment was not completed within the required timeframe following the start of hospice care. Interviews with facility staff confirmed the omission. The MDS Coordinator, an LPN, stated that she followed the RAI manual for assessment timing, and that either a corporate RN or the DON signed off on her completed assessments. However, both the MDS Coordinator and the Unit Manager/Infection Preventionist verified that the required Significant Change Assessment was not performed after the resident began hospice services, in direct contradiction to facility policy and federal guidelines.
Failure to Complete Timely Quarterly MDS Assessments
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed at least once every three months for three residents. According to the facility's policy and the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, quarterly assessments must be completed at least every 92 days following the previous OBRA assessment. Record reviews showed that one resident with chronic obstructive pulmonary disease and a collapsed vertebra, another with Alzheimer's disease and myasthenia gravis, and a third with heart failure and atrial fibrillation all had overdue MDS assessments, with the most recent assessments exceeding the required 92-day interval. Interviews with facility staff revealed that the MDS Coordinator was responsible for tracking and completing assessments using the electronic medical record (EMR) system and believed she was not behind in completing them. However, upon review, she confirmed that the assessments for the three residents were past due. The Regional Remote MDS nurse stated that she or the DON signed the MDS assessments but did not track the timing, and the DON expected the MDS Coordinator to complete assessments in a timely manner.
Inaccurate MDS Assessment and Coding of Pressure and Diabetic Ulcers
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two residents, resulting in deficiencies related to the documentation and coding of pressure ulcers and diabetic foot ulcers. For one resident with a history of atherosclerotic heart disease and dementia, medical records indicated the presence of a pressure ulcer to the sacrum as early as 10/2/2024, with subsequent documentation by a wound care physician describing the ulcer as unstageable and later as a Stage 4 pressure wound. However, the significant change MDS assessment completed on 10/17/2024 did not reflect the presence of any pressure ulcers or risk for developing them. Additionally, a quarterly MDS assessment incorrectly coded the Stage 4 sacral pressure ulcer as a deep tissue injury (DTI), despite clear documentation of its stage and characteristics in wound care notes. For another resident with diabetes and Alzheimer's disease, records showed ongoing treatment for a diabetic ulcer on the right lateral foot, including physician orders and wound care notes spanning several weeks. Despite this, the annual MDS assessment failed to document the presence of the diabetic foot ulcer or the associated skin treatments, instead indicating that the resident had no ulcers, wounds, or skin problems. Interviews with facility staff, including the MDS Coordinator, DON, and Regional Remote MDS nurse, confirmed that the assessments should have accurately reflected the residents' conditions and that the diabetic foot ulcer should have been coded on the MDS. The facility's policy required each individual completing a portion of the MDS to certify its accuracy, and the RAI Manual emphasized the importance of validating information for the specified observation period. Despite these requirements, the interdisciplinary team did not ensure that the MDS assessments accurately represented the residents' actual status, leading to incorrect coding and incomplete documentation of significant wounds and treatments.
Failure to Develop and Implement Person-Centered Care Plan for Diabetic Foot Ulcer
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident with a diabetic foot ulcer. Despite the resident having a history of diabetes and Alzheimer's disease, and documented orders for wound care including betadine application, the care plan was not updated to reflect the presence of the diabetic ulcer or the specific interventions recommended by the wound care provider. Documentation in the resident's medical record and wound progress notes indicated ongoing wound care and staff education regarding monitoring for infection, turning and repositioning, and the use of heel boots to relieve pressure. However, these interventions were not incorporated into the resident's official care plan prior to the resident's hospitalization. The resident's Minimum Data Set (MDS) did not indicate the presence of a diabetic foot ulcer or related treatment, and the care plan focus area for the ulcer was only initiated after the resident was discharged to the hospital with gangrene. Interviews with facility leadership confirmed that recommendations such as floating heels, heel booties, and frequent turning were made by the wound care provider and discussed in meetings, but these were not reflected in the care plan as required by facility policy. The lack of timely and comprehensive care planning had the potential to result in unmet care needs for the resident.
Failure to Provide Scheduled Showers for Dependent Resident
Penalty
Summary
A deficiency was identified when a dependent resident with diagnoses of congestive heart failure and dementia did not consistently receive scheduled showers as required by facility policy. The resident, who was severely cognitively impaired and required moderate assistance with activities of daily living, including toileting, hygiene, and bathing, was observed with greasy hair and saturated clothing due to incontinence. The facility's policy required showers for cleanliness, circulation, and comfort, with documentation of completion, and the care plan specified showers twice weekly, with alternative sponge baths if a full shower could not be tolerated. Interviews with CNAs confirmed that the resident was a heavy wetter, required frequent changing, and was sometimes resistant to care but could usually be persuaded to comply. However, review of shower documentation revealed that the resident did not receive all scheduled showers over several months, with missed showers in November, December, January, and March. An LPN acknowledged that showers were sometimes not completed due to staffing shortages. The lack of consistent showering created the potential for poor hygiene and odor, as observed during the survey.
Failure to Complete Quarterly Bed Rail Safety Assessments
Penalty
Summary
The facility failed to complete required quarterly assessments for the continued use and safety of bed rails for one resident. According to the facility's policy, bed rail use must be regularly assessed for safety risks, including factors such as medical condition, cognition, mobility, and risk of entrapment. For the resident in question, who had abnormal posture and kyphosis and was cognitively intact, there was documentation of an initial bed rail assessment and physician orders for bed rails to assist with positioning and safety. However, there were no documented quarterly bed rail assessments in the electronic medical record for the year, and only older paper assessments from before 2024 were found. Observations confirmed that the resident used full-length side rails and relied on them for repositioning due to her medical condition and fear of falling. Interviews with staff revealed that the required quarterly bed rail assessments had not been completed, and the process for triggering these assessments in the electronic system was not activated when the bed rail order was entered. The DON and RDCO both confirmed the absence of current bed rail assessments, acknowledging that this oversight was only recently discovered. This failure had the potential to affect all residents using bed rails in the facility.
Failure to Provide Timely Access to Prescribed Medications
Penalty
Summary
The facility failed to provide timely access to prescribed antibiotic and pain medications for three of five sampled residents, as required by their own policy and federal regulations. For one resident with severe cognitive impairment and a history of heart failure, daptomycin IV was not administered on multiple occasions due to the medication not being in stock, with documentation showing pharmacy notification and delayed delivery. Another resident with severe cognitive impairment and a diagnosis of C. difficile infection missed several doses of vancomycin oral suspension, with progress notes indicating the medication was on order and pending delivery from the pharmacy. Neither daptomycin nor vancomycin was available in the facility's contingency supply (Pyxis) at the time. A third resident, who was cognitively intact and had a history of neuropathy, diabetes, and hemiplegia, did not receive prescribed pain medications (Baclofen and Tramadol) on several occasions. Documentation revealed that Baclofen was out of stock and on order, and Tramadol was not available for three days, with repeated notes of awaiting pharmacy delivery. The resident reported experiencing pain during these periods without medication. Staff interviews confirmed ongoing issues with timely medication delivery from the pharmacy, difficulties accessing the Pyxis system (especially for agency nurses), and delays in reordering medications due to pharmacy policies. The facility's policy required prompt communication with the pharmacy for new and emergency medication orders, and the use of contingency supplies when available. However, interviews with nursing staff, the DON, and the infection preventionist confirmed that medications were not always delivered or available as needed, and that there were recurring problems with both pharmacy responsiveness and internal processes for medication reordering and access. These failures resulted in missed doses of critical antibiotics and pain medications for multiple residents.
Failure to Prevent Significant Medication Errors Due to Medication Unavailability and Access Issues
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors, as required by policy and regulation. For one resident with severe cognitive impairment and diagnoses including hypertensive heart disease and heart failure, multiple doses of critical medications (isosorbide dinitrate and metoprolol succinate) were not administered over several days following a recent hospital admission. Documentation indicated that these medications were not available due to pending pharmacy delivery, despite being stocked in the facility’s Pyxis emergency medication supply. Agency nurses reported not having access to the Pyxis and stated they informed management when unable to obtain medications. The nurse practitioner and DON confirmed that medications in the Pyxis should have been used if available, and that missed doses were reviewed by management. Another resident with diabetes mellitus and intact cognition did not receive a scheduled morning dose of insulin because the available vial had expired. The LPN identified the expired medication and contacted the on-call physician and pharmacy for a replacement, but the insulin was not available in the emergency kit and was not administered until later in the day. The resident’s blood sugar was elevated, and staff continued to monitor glucose levels throughout the day. The unit manager confirmed that the insulin was not in the emergency kit and that the resident’s sliding scale insulin was also unavailable due to a transcription error. Interviews with staff, including LPNs, the nurse practitioner, the DON, and the regional director, revealed ongoing issues with timely pharmacy deliveries, access to emergency medication supplies, and medication cart checks. Facility policies required the use of emergency kits and prompt notification of pharmacy and physicians when medications were unavailable, but these procedures were not consistently followed, resulting in significant medication errors for both residents.
Failure to Implement and Follow Infection Control Practices for PPE and Precautions
Penalty
Summary
The facility failed to follow its own infection prevention and control policies for two residents regarding the use of personal protective equipment (PPE) and the implementation of enhanced barrier precautions (EBP) and transmission-based precautions. For one resident with a gastrostomy tube, staff did not don a gown while performing high-contact care activities such as checking tube placement, flushing the tube, and administering medication, despite facility policy and posted signage requiring both gloves and a gown for such activities. Additionally, the signage for EBP was posted inside the room, and PPE supplies were only available inside, not outside the room as required for proper donning before entry. A visitor was also allowed to enter the room without any PPE, and staff demonstrated confusion about which resident the posted precautions applied to. For another resident diagnosed with Clostridium difficile, there was a lack of clear identification regarding which resident in a shared room was on EBP or transmission-based precautions. Staff interviews revealed inconsistent understanding of when and for whom EBP should be used, with some staff relying on verbal reports rather than clear signage. PPE was not available outside the room for staff to don before entry, contrary to facility policy and standard infection control practices for transmission-based precautions. Interviews with nursing staff and facility leadership highlighted discrepancies in knowledge and application of EBP and transmission-based precautions. Some staff believed EBP was not required for certain activities, such as flushing or administering medications via a gastrostomy tube, while others stated that gowns and gloves should be used for all high-contact care. The facility's policies and CDC guidelines were not consistently followed, and there was confusion about the placement of PPE and signage, leading to lapses in infection control practices.
Unlocked Cabinets in Shower Rooms Pose Hazard
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards by not keeping cabinets locked in the shower rooms on A and B Halls. These cabinets contained potentially dangerous items such as cleaning supplies, toiletries, and disposable razors. Observations revealed that the cabinet in the A Hall shower room was unlocked with a broken lock, and the cabinet in the B Hall shower room was also unlocked with no lock present. This oversight had the potential to harm two residents who were known to wander the facility. Interviews with staff, including an LPN and a CMA-Tech, confirmed the unlocked status of the cabinets. The Director of Nursing (DON) was unaware of the situation and speculated that the keys might have been lost, leading to the locks being broken without informing the administration. The facility's policy on maintaining shower rooms and supplies was requested but not provided before the survey exit. The Administrator later confirmed that two residents were known to wander the facility, typically staying in the hallways.
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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