Blue Ridge Care Center Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Dallas, Georgia.
- Location
- 600 West Memorial Drive, Dallas, Georgia 30132
- CMS Provider Number
- 115258
- Inspections on file
- 20
- Latest survey
- December 7, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Blue Ridge Care Center Llc during CMS and state inspections, most recent first.
Dietary staff did not label or date opened food items and failed to properly discard expired milk. Unlabeled opened cheese and teriyaki sauce were found in storage, and expired chocolate milk was stored with other milk without appropriate signage. The DOD confirmed these lapses and acknowledged responsibility for oversight.
Surveyors found that the facility's dish machine was not properly sanitizing dishware, as temperature gauges were not functioning and sanitizer was not being dispensed, despite multiple tests and recent repairs. This deficiency was identified while nearly all residents were receiving oral diets, and was confirmed through staff interviews and direct observation.
A resident with paraplegia and severe cognitive impairment had personal and medical information posted on their wall, including birthday, gender, medical ID, and a picture. This posting was observed on multiple occasions, and interviews with a family member, the UM, and the DON confirmed that such information should not have been displayed, violating privacy policies.
A resident with depression, anxiety, and other medical conditions received PRN alprazolam for anxiety beyond the 14-day limit required by facility policy. The order was entered with an indefinite stop date, and the medication was administered on multiple occasions past the allowed timeframe. Staff confirmed the expectation for a 14-day limit on PRN psychotropic medications, but the order and administration did not comply with this policy.
The facility did not develop or implement comprehensive care plans for four residents with specialized needs, including those with indwelling urinary catheters, oxygen therapy, and psychotropic medication use. Despite physician orders and documented assessments, care plans lacked necessary focus areas and interventions, as confirmed by staff interviews and record reviews.
A resident with severe cognitive impairment and protein calorie malnutrition was not given a physician-ordered frozen nutritional supplement with meals due to a supply shortage and miscommunication among dietary staff. The supplement was omitted from the resident's lunch tray, and no alternative was provided, despite facility policy requiring supplements to meet assessed needs.
Two residents received oxygen therapy not in accordance with physician orders, including continuous administration when only as-needed use was ordered and at higher flow rates than prescribed. Staff failed to document oxygen administration and did not specify whether oxygen saturation readings were on room air or oxygen. Additionally, required equipment maintenance and safety signage were not followed, as oxygen concentrators lacked filters and 'oxygen in use' signs were missing.
A resident with severe cognitive impairment and a diagnosis of protein calorie malnutrition was not served the lunch meal as written on the facility menu or tray slip. Instead of chicken parmesan, the resident received plain steamed chicken, despite staff and family confirming the discrepancy. Both the Administrator and DOD acknowledged the resident should have received chicken parmesan without sauce, as is the usual practice for residents preferring no sauces.
A CNA did not follow proper hand hygiene and glove-changing protocols while providing catheter care to a resident with an indwelling urinary catheter. The CNA performed care tasks without washing or sanitizing hands between steps and did not change gloves as required, contrary to facility policy and physician orders.
The facility did not revise its CLIA certificate within the required 30 days after a change in ownership, continuing to operate under the previous owner's certificate for approximately seven months. The Administrator confirmed the ongoing use of the prior waiver, and the State CLIA Department verified the facility was out of compliance.
Surveyors observed that bath linens provided to residents were often torn, tattered, or insufficient across multiple hallways. Staff and residents reported frequent shortages, with some towels being cut up to make washcloths. Linen carts were found lacking, and several residents displayed damaged linens from their rooms. Facility leadership acknowledged that such linens should not be used.
Surveyors observed expired food items, including a loaf of bread with visible mold and sandwiches and apples past their use-by dates, stored in resident snack areas on two units. Staff confirmed these items should have been discarded per facility policy, indicating a failure to follow professional standards for food storage and safety.
A CNA assisted multiple residents with eating without performing hand hygiene before or between assisting different individuals, despite touching her own hair, face, cell phone, and food directly with bare hands. Interviews with staff and review of facility policy confirmed that hand hygiene was required before and after assisting with meals, but these protocols were not followed during the observed lunch meal service.
A resident was observed eating at a table that was too high, with her upper lip at table height, making it difficult for her to see her food and eat independently. Staff interviews confirmed that the resident should have been seated at a smaller or adjustable table to promote dignity and facilitate eating.
The facility failed to maintain clean oxygen concentrator filters for two residents requiring oxygen therapy. Observations revealed that the filters were covered with a thick, white substance, indicating they had not been cleaned as required by the facility's policy. Interviews with staff confirmed the deficiency, highlighting a lapse in adherence to the maintenance schedule.
Failure to Label Opened Food Items and Discard Expired Milk
Penalty
Summary
Dietary staff failed to label and date opened food items and did not properly discard expired milk, as required by facility policy. Observations revealed a five-pound bag of shredded cheddar cheese and a one-gallon container of teriyaki sauce that had been opened and stored without an open date. The Director of Dietary (DOD) confirmed these items were not labeled as required and stated that all dietary staff were responsible for labeling and dating, but she was ultimately responsible for checking compliance. The DOD had not yet checked the walk-in refrigerator on the day of the observation. Additionally, a full crate of eight-ounce chocolate milk cartons with a sell-by date that had passed was found stored next to other milk crates without a 'do not use' sign. The DOD acknowledged that expired milk should be separated and marked accordingly but admitted to noticing the expired crate and forgetting to move it and label it. At the time of the survey, the facility census was 163, with 162 residents receiving an oral diet.
Failure to Maintain Proper Dish Machine Sanitization
Penalty
Summary
The facility failed to ensure that the dish machine used for sanitizing dishware was functioning properly to prevent foodborne illness. Observations revealed that the large conveyor belt type dish machine, which operates as a low temperature chemical sanitizing unit, had non-functioning temperature gauges and was not dispersing sanitizer as required by facility policy. Multiple attempts to test the sanitizing solution using paper test strips showed no indication of sanitizer being present, as the strips remained white instead of turning black to indicate the required concentration. Staff, including the dietary aide, Director of Dietary (DOD), and Director of Maintenance (DOM), confirmed these findings during the survey. The issue persisted despite staff checking chemical buckets, tubing, and replacing the sanitizer bucket. The temperature gauges on the dish machine were also not registering any temperatures for the wash or rinse cycles during several observations. The DOD and DOM both confirmed that the dish machine had recently undergone repairs and had been out of operation for several days while waiting for a part. However, even after the machine was reported as fixed and the temperature gauges began working again, repeated tests continued to show no sanitizer being dispensed. The deficiency was observed while 162 out of 163 residents were receiving an oral diet, indicating that the majority of residents could have been affected by improperly sanitized dishware. The failure to maintain essential equipment in safe working order was confirmed through direct observation, staff interviews, and review of facility policy, with the dish machine only beginning to dispense sanitizer after multiple interventions and repeated testing.
Failure to Protect Resident Health Information Privacy
Penalty
Summary
The facility failed to protect the privacy of a resident's health information by posting instructions on the resident's wall that disclosed personal details, including birthday, gender, medical identification, and a picture. This posting was observed on two separate occasions and was titled with the resident's shower day, making private medical information visible. The facility's policy on promoting and maintaining residents' dignity specifically requires maintaining resident privacy, which was not followed in this instance. The resident involved had a diagnosis of paraplegia and severe cognitive impairment, as indicated by a BIMS score of 00 on the most recent assessment. Interviews with a family member, the Unit Manager, and the DON confirmed that the posting of such information was inappropriate and not in line with facility policy or HIPAA requirements. The family member was unaware of the posting, and both the Unit Manager and DON acknowledged that staff should not post residents' medical information in this manner.
Failure to Limit PRN Psychotropic Medication Orders to 14 Days
Penalty
Summary
The facility failed to ensure that as-needed (PRN) psychotropic medication orders were limited to 14 days as required by policy for one resident. The policy on the use of psychotropic medications specified that PRN orders should not exceed 14 days unless the prescriber documents a rationale for extending the order and specifies a duration. However, a review of the electronic medical record (EMR) for a resident with diagnoses including depression, anxiety, diabetes mellitus type 2, and urinary tract infection revealed an order for alprazolam 0.25 mg every 12 hours as needed for anxiety, with an indefinite stop date. The resident was cognitively intact, as indicated by a BIMS score of 15, and the care plan did not address the use of antianxiety or antidepressant medications. Medication administration records showed that alprazolam was administered multiple times beyond the 14-day limit set by policy, with doses given on several dates in both November and December after the initial order date. Staff interviews confirmed that PRN psychotropic medications are expected to be limited to 14 days, but the order in question was entered with an indefinite stop date by the Nurse Practitioner. Both the LPN and DON verified that the medication was administered outside the required timeframe, confirming the deficiency in following the facility's policy regarding PRN psychotropic medication orders.
Failure to Develop Comprehensive Care Plans for Residents with Specialized Needs
Penalty
Summary
The facility failed to develop and implement person-centered comprehensive care plans for four residents, as required by facility policy and professional standards. Specifically, one resident with an indwelling urinary catheter did not have a care plan addressing catheter care, despite physician orders detailing the need for ongoing catheter management and enhanced barrier precautions. The MDS Coordinator confirmed that no care plan was in place for this resident, acknowledging that such a plan should have been completed following the admission assessment. Two other residents who were receiving oxygen therapy also lacked care plans addressing their oxygen use. Both residents had documented orders for oxygen administration and were observed receiving oxygen during the survey. Staff interviews confirmed that the care plans did not include focus areas or interventions related to oxygen therapy, even though this was documented in their assessments. The DON and MDS Coordinator both verified that oxygen use should have been included in the care plans for these residents. A fourth resident, who was prescribed antianxiety, antidepressant, and hypoglycemic medications, did not have a care plan addressing the use of these psychotropic and high-risk medications. The resident's medication use was documented in the MDS assessment, but the care plan lacked any focus areas, goals, or interventions related to these medications. Multiple staff members, including LPNs and the DON, confirmed that interventions for these medications should have been present in the care plan and were unable to explain why they were missing.
Failure to Provide Ordered Nutritional Supplement with Meals
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of unspecified protein calorie malnutrition was not provided with a physician-ordered frozen nutritional supplement during a lunch meal. The resident had a severely impaired cognitive status, as indicated by a Brief Interview for Mental Status (BIMS) score of one out of 15. Review of the resident's electronic medical record confirmed an active order for the supplement to be given with meals. During observation, the lunch tray did not include the supplement, and the resident was only offered a meal plate, iced tea, and Italian ice. The resident's family member confirmed the absence of the supplement and noted that the resident had previously received and enjoyed it. Interviews with facility staff revealed that the dietary department was out of the frozen nutritional supplement and was awaiting a new supply from their food supplier. The Director of Dietary (DOD) was unaware that the supplement was to be given with meals, mistakenly believing it was to be provided between meals. The registered dietitian confirmed the supply issue and stated that the resident had previously refused liquid supplements, but no alternative, such as regular ice cream, was offered during the shortage. The facility's policy required providing nutritional supplements consistent with assessed needs, but this was not followed in this instance.
Failure to Administer Oxygen Therapy as Ordered and Maintain Equipment Protocols
Penalty
Summary
The facility failed to ensure that oxygen was administered as ordered by the physician for two residents who were receiving oxygen therapy. For one resident with diagnoses including epilepsy, acute respiratory distress, and pneumonia, the physician's order specified oxygen at two liters per minute (LPM) via nasal cannula (NC) only if oxygen saturation fell below 90%, with instructions to call the physician immediately after placement. However, the resident was observed receiving oxygen at four LPM continuously, despite no documentation of oxygen saturations below 90% or respiratory distress, and staff confirmed there were no changes in orders or status to justify this deviation. For another resident with shortness of breath and asthma, the physician's order was for oxygen at two LPM via NC as needed for oxygen saturation below 90%, with a requirement to call the physician after placement. This resident was observed receiving continuous oxygen, and staff confirmed that the order was for as-needed use, not continuous administration. Additionally, there was no care plan addressing oxygen use for this resident, and documentation did not specify whether pulse oximeter readings were taken on room air or while on oxygen. Staff also failed to document the administration of oxygen as required by the as-needed order. Further deficiencies were observed in the maintenance and safety protocols for oxygen therapy. The oxygen concentrator for the second resident was missing a required filter, which should have been cleaned or replaced weekly according to physician orders. There was also no 'oxygen in use' signage on the resident's doorway, as required by facility policy. Staff interviews confirmed these lapses in following physician orders and facility protocols for oxygen administration and equipment maintenance.
Failure to Serve Menu Meal as Written for Resident with Malnutrition
Penalty
Summary
The facility failed to serve a lunch meal as written on the menu for one sampled resident who had a diagnosis including unspecified protein calorie malnutrition and severely impaired cognition. The resident had a physician order for a regular diet, regular texture, and regular consistency. According to the facility's posted menu, the lunch meal was supposed to include chicken parmesan, spaghetti, tomato sauce, Italian mixed vegetables, garlic roll, margarine, Italian ice, and whole milk. However, the resident's meal tray slip listed substitutions, including fried chicken with no sauce, noodles with no gravy, and other items. Observation revealed the resident was served plain steamed chicken thigh, Italian mixed vegetables, garlic bread, iced tea, and Italian ice, rather than the chicken parmesan specified on both the menu and the tray slip. Interviews with the resident's family member, the Administrator, and the Director of Dietary confirmed that the resident was not served the chicken parmesan as indicated. The family member reported that the resident was often not served what was indicated on the meal tray slip. Both the Administrator and the Director of Dietary acknowledged that, despite the resident's preference for no sauces or gravy, the resident should have been served chicken parmesan without sauce, as per the menu and tray slip. The Director of Dietary also stated that cooks typically set aside unsauced chicken parmesan for residents who prefer no sauces, but this was not done in this instance.
Failure to Follow Hand Hygiene Protocol During Catheter Care
Penalty
Summary
A deficiency was identified when a Certified Nursing Assistant (CNA) failed to follow proper infection control practices during catheter care for a resident with an indwelling urinary catheter. The CNA was observed double-gloving before entering the resident's room and did not clean the bedside table before setting up supplies. During the catheter care process, the CNA removed only the outer pair of gloves after cleaning the catheter insertion site but continued the remainder of the care, including rinsing, drying, and repositioning the resident, with the same inner gloves. At no point during the procedure did the CNA wash or sanitize her hands when transitioning between clean and dirty tasks, nor did she don new gloves as required by facility policy and professional practice standards. The resident involved had a history of urinary retention, severely impaired cognition, and was dependent on staff for all activities of daily living. The resident's care plan did not include specific interventions for the indwelling urinary catheter, despite physician orders outlining catheter care and enhanced barrier precautions. Facility policy and audit tools specifically required hand hygiene and glove changes during catheter care, but these protocols were not followed during the observed incident.
Failure to Update CLIA Certificate After Change of Ownership
Penalty
Summary
The facility failed to update its Clinical Laboratory Improvement Amendments (CLIA) certificate within 30 days following a change in ownership, as required by regulations. Approximately seven months after the new owner acquired the facility, the CLIA Certificate of Waiver and the CLIA Certificate of Compliance remained in the name of the previous owner and previous laboratory service owner, respectively. During an interview, the facility's Administrator acknowledged that the facility was still operating under the previous owner's waiver as part of the transition. The State CLIA Department confirmed that the facility was out of compliance and should have requested a revised CLIA certificate using the CMS-116 application within the required timeframe.
Failure to Provide Adequate and Clean Bath Linens
Penalty
Summary
Surveyors found that the facility failed to provide bath linens in good condition across seven of nine hallways. During multiple observations, linen carts were found to have either no towels or washcloths, or only those that were torn and in disrepair. Staff were seen using tattered washcloths, and some reported that they often lacked adequate linens, with new linens only being provided during the survey. Residents confirmed that towels had been cut up to make washcloths, and several displayed torn and shredded linens from their personal supplies. Resident Council minutes and grievance logs documented ongoing complaints about daily linen shortages affecting all units. Interviews with staff and administration revealed that families and residents had been cutting up towels to create washcloths, and that staff sometimes had to ration or redistribute available linens. The Environmental Service Supervisor and Administrator acknowledged the issue, with the Administrator stating that linens should not be cut up or used in a damaged state. Photographic evidence of shredded washcloths was presented to facility leadership, who agreed that such items should not be in use.
Expired Food Found in Resident Snack Storage Areas
Penalty
Summary
Staff failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, as evidenced by the presence of expired food in resident snack storage areas. On two separate units, surveyors observed an unopened loaf of bread with an expiration date several months past, which was hard and showed green discoloration, and a refrigerator containing turkey sandwiches and cups of apples that were past their use-by dates. Staff interviews confirmed that these food items should have been discarded according to facility policy, which requires perishable and leftover foods to be labeled with preparation and discard dates and disposed of within a specified timeframe.
Failure to Perform Hand Hygiene During Meal Assistance
Penalty
Summary
Staff failed to perform proper hand hygiene during the lunch meal service in the Nursing Unit Main Dining Room, as observed with three residents. A Certified Nursing Assistant (CNA) assisted residents with eating without using hand sanitizer or washing hands before or between assisting different residents. The CNA was observed touching her own hair, face, and cell phone, as well as handling utensils and food directly with bare hands, and then continuing to assist residents with their meals without performing hand hygiene. The CNA also distributed meal trays and adjusted the television without washing hands before returning to assist residents with eating. Interviews with the CNA, the Nursing Unit Manager (LPN), the Director of Nursing (DON), and facility administrators confirmed that staff are expected to use hand sanitizer or wash hands before serving or feeding residents, and after touching their face or hair. The facility's policy on hand hygiene requires the use of alcohol-based hand rub before and after assisting a resident with meals. The observed failure to follow these protocols occurred during the lunch meal and involved multiple residents who required assistance with eating.
Failure to Provide Appropriate Table Height Compromises Resident Dignity During Meals
Penalty
Summary
A deficiency occurred when a resident was not provided with a dining table of appropriate height, resulting in the resident being unable to see her food while eating. Observations showed the resident seated in a lowered wheelchair at a table where her upper lip was at table height, making it difficult for her to eat independently and with dignity. Staff interviews confirmed awareness of the issue, with a CNA noting that the resident should have been seated at a smaller table to allow her to see her food. The DON and Administrator acknowledged that the resident should have been provided with an adjustable or smaller table, and the Regional Director of Operations also stated that the resident should sit at a smaller table. The failure to provide a suitable table height compromised the resident's dignity during mealtime.
Failure to Maintain Clean Oxygen Concentrator Filters
Penalty
Summary
The facility failed to maintain a clean oxygen concentrator filter for two residents, R56 and R119, who required oxygen therapy. The facility's policy mandated that the oxygen concentrator filter be cleaned weekly and as needed, with documentation on the Medication Administration Record (MAR). However, observations revealed that the filters on both residents' oxygen concentrators were covered with a thick, white substance, indicating they had not been cleaned as required. Interviews with staff, including the Dementia Unit Manager and the Director of Nursing, confirmed that the filters appeared unclean and that the maintenance was supposed to be conducted by the third shift nurse every Wednesday and as needed. R56 was admitted with diagnoses including chronic obstructive pulmonary disease (COPD) and emphysema and had a care plan that required regular maintenance of the oxygen concentrator. Despite this, multiple observations on consecutive days showed that the filter was not cleaned. The Dementia Unit Manager confirmed that the filter did not appear to have been cleaned during the previous third shift as indicated on the MAR. Similarly, R119, who was admitted with acute respiratory failure with hypoxia, also had an unclean oxygen concentrator filter. Observations and interviews confirmed that the filter was covered with a thick, white substance, and the Dementia Unit Manager verified that it did not appear to have been cleaned as required. Interviews with a Certified Nursing Assistant and a Licensed Practical Nurse revealed that the responsibility for cleaning the oxygen concentrator filters lay with the nurses assigned to the residents' hall. The Director of Nursing stated that her expectation was for the third shift nurse to clean the concentrators weekly and document the activity, but all nursing staff were responsible for ensuring the equipment was clean and free of debris. Despite these expectations, the observations and interviews indicated a failure to adhere to the facility's policy, leading to the deficiency in maintaining clean oxygen concentrator filters for the residents involved.
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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