Bonterra Transitional Care & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in East Point, Georgia.
- Location
- 2801 Felton Drive, East Point, Georgia 30344
- CMS Provider Number
- 115555
- Inspections on file
- 15
- Latest survey
- March 19, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Bonterra Transitional Care & Rehabilitation during CMS and state inspections, most recent first.
A resident with severe dysphagia and cognitive impairment, who required a pureed diet with thin liquids, was given a sandwich by a CNA, contrary to their care plan and physician orders. The resident choked, required emergency intervention, was hospitalized, transferred to hospice, and later died. The facility failed to implement the care plan and provide the prescribed diet, resulting in serious harm.
A resident with severe cognitive impairment and dysphagia, who was ordered a pureed diet, was given a sandwich by a CNA, contrary to physician orders and care plan directives. The resident subsequently choked on the food, requiring emergency intervention, and later died after being transferred to a hospice facility. Investigation confirmed neglect and policy violations related to dietary management.
A resident with an order for a mechanically altered diet was given a sandwich by a CNA, contrary to the prescribed pureed snack. This led to the resident being sent to the ER, transferred to hospice, and subsequently expiring. The Administrator and DON were aware of the incident, which was determined to be noncompliance with federal requirements for quality of care and care planning, resulting in Immediate Jeopardy.
A resident with recent lower extremity amputations experienced unmanaged pain and embedded surgical staples after the facility failed to arrange transportation for a post-op appointment. Despite care plans and physician orders for pain management, the resident's pain persisted due to missed staple removal, and staff were aware of the discomfort but did not ensure timely intervention.
A resident with recent amputation surgery and complex medical needs missed a scheduled staple removal appointment because the facility failed to arrange transportation. The appointment was rescheduled and canceled without notifying the family, and the resident experienced pain and embedded staples as a result. Staff interviews and record reviews confirmed lapses in communication and transportation coordination.
The facility did not maintain an effective Antibiotic Stewardship program, as evidenced by missing lab orders, unresolved antibiotic stop dates, lack of documentation on antibiotic duration, and inadequate monitoring of residents with infections, especially those admitted or transferred from hospitals. The IP Nurse confirmed that lab follow-up and infection tracking were not consistently performed, and the DON and Administrator acknowledged expectations for adherence to policy.
Handrails in two wings were repeatedly blocked by dressers due to ongoing construction, making them inaccessible for residents who require support for ambulation. Additionally, a resident with a history of dementia and substance abuse was found with multiple medications at bedside without a physician's order or an assessment for self-administration, contrary to facility policy. The DON and Administrator confirmed both deficiencies.
Multiple medication carts were observed left unlocked and unattended by staff, including LPNs and a CMA, despite facility policy and recent in-service training requiring carts to be locked when not in use. Staff confirmed the presence of various medications, including narcotics, in the unsecured carts and acknowledged the expectation to keep carts locked at all times.
Staff prepared pureed food without following a formal recipe, instead relying on personal experience to determine ingredient amounts and consistency. The Dietary Kitchen Manager confirmed that no current recipe was used, and the Administrator stated that recipes should be followed to ensure proper consistency. This practice had the potential to affect six residents on a pureed diet.
Surveyors found that staff failed to properly label and date opened food items in the pantry and cooler, did not adequately cover or seal some foods, and did not maintain the ice machine free of debris. These actions were inconsistent with facility policies and had the potential to affect all residents receiving food orally.
The facility did not maintain proper infection surveillance and monitoring, with missing documentation, incomplete tracking, and absent infection criteria in the Infection Control Book. Additionally, personal clothing was improperly stored on a linen cart, and clean laundry was transported uncovered in hallways, contrary to infection control protocols.
The facility did not provide effective behavioral health training aligned with its facility assessment, as evidenced by multiple staff interviews and record reviews showing a lack of education on schizophrenia, mental disorders, and PTSD. Several residents with these diagnoses had care plans addressing complex behavioral needs, but staff—including CNAs, LPNs, RNs, agency staff, and non-clinical personnel—reported little or no training on these conditions. Training records and orientation materials lacked content specific to behavioral health, and agency staff and volunteers did not receive documented instruction on these topics.
A resident who is cognitively intact and dependent on staff for ADLs was provided personal care with the door to her room left open, despite facility policy requiring privacy during such care. Staff and the DON confirmed that the door should have been closed, and the resident reported the incident herself, indicating a failure to maintain dignity and privacy.
A resident room was observed with brown stains on the wall, identified as feces thrown by a roommate, which remained uncleaned over several days. Housekeeping staff did not address the stains despite facility policy requiring cleaning of visibly soiled surfaces, and both the Housekeeping Director and Administrator confirmed that walls are expected to be kept clean and sanitary.
A resident with significant pain management needs was prescribed oxycodone, but the facility failed to maintain accurate records and secure the medication, resulting in missing doses and unaccounted pills. Staff provided inconsistent documentation and statements, and the required controlled drug sheet was missing, leading to the misappropriation of the resident's prescribed narcotics.
A resident admitted with a prescription for oxycodone experienced a discrepancy in the number of pills received and administered, with all medication reportedly gone within three days and missing documentation. Despite facility policy and staff acknowledgment that such incidents are reportable, the suspected misappropriation of narcotics was not reported to the State Survey Agency.
The facility did not obtain Level II PASARR screenings for two residents with mental health diagnoses, including schizoaffective disorder and PTSD, despite clear indications in their records and care plans. Staff interviews revealed a lack of awareness about which conditions require Level II PASARR, resulting in non-compliance with facility policy and federal requirements.
A resident with moderate cognitive impairment and dependence on staff for personal hygiene did not receive proper nail care, despite requesting assistance and not refusing the service. Staff and observations confirmed the resident's fingernails remained long and unclean, contrary to facility policy and care expectations.
Two residents receiving oxygen therapy were not administered oxygen at the rates ordered by their physicians. One resident with COPD and respiratory failure received higher oxygen flow rates than prescribed, while another resident with pulmonary embolism and emphysema also received oxygen at a higher rate than ordered. Staff interviews confirmed that nursing staff are responsible for verifying and setting the correct oxygen rates, but this was not consistently done.
A resident with moderate cognitive impairment and significant oral pain due to a loose tooth did not receive timely dental services, despite repeated assessments noting the issue and daily reports of pain to nursing staff. The required referral process was not completed, and the resident was not referred to the in-house dental program, even though they qualified for Medicaid dental benefits. Staff interviews confirmed breakdowns in communication and failure to follow the facility's dental services policy.
A resident with severe cognitive impairment and dependence on staff for ADLs was left without a functional call system after a nurse repeatedly told the resident not to use the call device and the call system cord was found unplugged. Facility policy required call lights to be accessible and answered promptly, and the DON confirmed staff should not instruct residents not to use the call device.
Failure to Follow Care Plan Results in Resident Choking and Death
Penalty
Summary
A deficiency occurred when a resident with a history of dysphagia following cerebral infarction, oropharyngeal phase dysphagia, cerebrovascular disease, adult failure to thrive, and severe cognitive impairment was not provided care in accordance with their comprehensive care plan. The resident's care plan and physician orders specified a mechanically altered, pureed diet with thin liquids due to their swallowing difficulties and risk of choking. Despite these documented dietary restrictions, the resident was given a sandwich by a Certified Nursing Assistant (CNA), which was not consistent with the prescribed diet. The incident was observed when the resident, while sitting in a wheelchair at the nursing station, began choking on undigested food. Food was seen falling from the resident's mouth, and the resident was struggling to breathe. Immediate interventions, including the Heimlich maneuver and a mouth sweep, were attempted by an LPN but were unsuccessful. Cardiopulmonary resuscitation (CPR) was initiated, and emergency services were called. The resident eventually started breathing again and was transported to the hospital by EMS. Following the event, it was determined that the resident was admitted to a hospice facility after hospital discharge and subsequently expired. The facility's failure to implement the resident's care plan and provide the appropriate diet as ordered directly led to the choking incident and the resident's transfer to the hospital, hospice admission, and eventual death. The survey identified this as noncompliance with federal requirements for comprehensive care planning and quality of care.
Removal Plan
- The facility's Modified Texture of Food Policy, Care Plan Policy, and Resident Food Preferences Policy were reviewed and staff in-service education was initiated. All policies were reviewed with 100% staff except those on Leave of Absence and Family Medical Leave Act.
- An Ad Hoc QAPI meeting was held with key facility leadership and staff to review the IJ Removal Plan. The Care Plan policy was reviewed with no changes. A Daily Diet Verification Audit was performed for 100% of current residents to ensure meal tray cards matched diet orders, Kardex, and care plans.
- No staff worked until they had completed the in-service education. Part-time, PRN, and contracted staff will be in-serviced and educated on the relevant policies before being allowed to work.
- All newly hired staff will be in-serviced on their first day of hire during orientation, annually, and quarterly. Individuals will not work until they have received this in-service/training. All residents' care plans were reviewed and updated to reflect appropriate diet orders.
- The facility implemented interventions to minimize environmental risks and hazards, including Daily Diet Verification Audit, Snack Distribution Audit, and Meal Tray Observation Audit for 100% of current residents. Education was provided to all staff regarding relevant policies and reporting procedures.
- New interventions will be monitored by the DON for effectiveness using audit tools. If a problem is identified, it will be addressed by the Food Service Director, Administrator, DON, and Medical Director, with possible Ad Hoc QAPI meetings and corrective action if necessary.
Failure to Provide Prescribed Pureed Diet Results in Resident Choking and Death
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of dysphagia, oropharyngeal phase, was not provided with the prescribed pureed diet. The resident was admitted with multiple diagnoses, including dysphagia following cerebral infarction, cerebrovascular disease, adult failure to thrive, and required supervision or assistance with eating. Physician orders and the care plan specified a no added salt (NAS), pureed/dysphagia puree texture, and thin liquids consistency diet. Despite these orders, the resident was given a sandwich by a Certified Nursing Assistant (CNA), as confirmed by camera footage and staff interviews. The facility's policies required careful reading of tray cards to ensure correct food textures were served, and the risks and benefits of specialized diets were to be communicated by the physician and dietician. On the day of the incident, the resident was observed pointing to a snack tray, after which the CNA handed him a sandwich. Shortly after, the resident was found choking on undigested food at the nurse's station, with food falling from his mouth and difficulty breathing. Staff attempted the Heimlich maneuver and a mouth sweep, but initial efforts were unsuccessful. Emergency services were called, and CPR was performed until the resident was transported to the emergency room. Subsequent investigation substantiated the allegation of neglect, and the CNA involved was terminated. The resident was later transferred to a hospice facility, where he expired. The facility's failure to follow prescribed diet orders and care plan interventions directly led to the resident receiving an inappropriate food item, resulting in a choking incident and subsequent death.
Removal Plan
- Review and update the facility's Modified Texture of Food Policy, Care Plan Policy, and Resident Food Preferences Policy; initiate staff in-service education on these policies.
- Hold an AdHoc QAPI meeting with key facility leadership to review the IJ Removal Plan and Care Plan policy.
- Perform a Diet Verification Audit for 100% of current residents to ensure meal tray cards match diet orders, Kardex, and care plans.
- Provide in-service education to all staff, including administrative, nursing, dietary, housekeeping, maintenance, and activities staff, on relevant policies.
- Require that no staff work until they have completed the in-service education; ensure all part-time, PRN, and contracted staff are educated before working.
- Implement a process for all newly hired staff to be in-serviced during orientation, with annual and quarterly retraining.
- Review and update all residents' diet orders and care plans to ensure accuracy.
- Implement environmental interventions including Diet Verification Audit, Snack Distribution Audit, and Meal Tray Observation Audit for all residents.
- Educate all staff on reporting unmatched meal trays and diet orders to the Food Service Director and Director of Nursing.
- Report all audit findings to the QAPI Committee and conduct an Ad Hoc QAPI meeting.
- Monitor new interventions for effectiveness using audit tools; address identified problems with the Food Service Director, Administrator, DON, and Medical Director.
- Establish a process for meetings with all relevant parties if a policy violation occurs, with escalation to Ad Hoc QAPI meeting and corrective action if needed.
- Validate completion of all corrective actions and removal of Immediate Jeopardy status.
Failure to Follow Care Plan for Mechanically Altered Diet Results in Resident Death
Penalty
Summary
The facility failed to implement and follow the care plan for a resident who was ordered to receive a mechanically altered diet. Despite the resident's dietary restrictions, a Certified Nursing Assistant (CNA) provided the resident with a sandwich, which was not consistent with the prescribed pureed snack. This action was observed by the Administrator through facility camera footage. As a result of receiving the inappropriate food item, the resident was sent to the local emergency room and subsequently transferred to a hospice facility, where the resident expired. The incident was recognized as a failure to comply with federal regulatory requirements related to quality of care and comprehensive care planning for residents with altered diets. The Administrator and Director of Nursing were aware of the incident and acknowledged that the resident's care plan was not followed. The facility's noncompliance was determined to have caused or had the likelihood to cause serious injury, harm, impairment, or death to residents, leading to the identification of Immediate Jeopardy for multiple federal regulations.
Removal Plan
- An Ad Hoc Quality Performance Improvement (QAPI) meeting was held with the Administrator, Social Services Director (SSD), the DON, Corporate Operations Consultant (COC), and Food Service Director (FSD) to identify the root cause of failure to follow R165's care plan. The facility's Modified Texture of Food Policy, Care Plan Policy, and Resident Food Preferences Policy were reviewed; no changes were made.
- The Administrator's job description was reviewed with the Administrator, FSD, SSD, and DON by the COC. No revisions were made.
- The COC in-serviced the Administrator, DON, FSD, and SSD on how to implement a process on how to verify diet orders before distributing resident meal trays, how to track and trend to determine a root cause analysis, and communication among departments on reviewing and updating resident care plans timely. The facility's QAPI policy was reviewed specifically regarding how to determine root cause analysis (RCA).
- The COC reviewed and approved the facility's audit forms and Plan of Correction (PoC) for any further areas of concern. Name of Audits- Daily Diet Verification Audit and Snack Distribution Audit. Residents' diets and care plans were discussed with the Administrator, DON, and FSD. Interventions were put into place, such as removing accessible snacks from the nurse stations; snacks were placed inside the pantry and available upon request. A snack diet reference sheet was initiated and placed inside the pantry.
- The Corporate Nurse Consultant (CNC) and DON audited the resident's diet orders and meal tray cards. The audits are named Daily Diet Verification Audit and Snack Distribution Audit. The Administrator, DON, and FSD will discuss all diet order changes in the morning and the clinical meeting to ensure all care plans are updated and accurate. Documentation will be monitored through the Abuse Performance Improvement Plan (PIP) and reported during QAPI by the DON and Administrator. The SSA reviewed and compared Diet Master from the Dietary Department and the Facility's Diet Type Report for all residents in the facility; no discrepancies were found.
- The COC met with the Administrator and DON to review the process of providing direct oversight of the following correct processes in the building as it relates to following care plans for resident diet orders. There is ongoing educational training for all members of the facility through the company's online courses. The Administrator was also in-service on how to conduct a QAPI meeting and how to identify and complete an RCA by the COC. The SSA reviewed in-service education related to the QAPI meeting and RCA with no concerns.
- The corrective actions were completed, and the facility alleges that the immediate jeopardy was removed. All corrective actions were completed. The facility's IJ was determined to be Past Noncompliance, removed.
Failure to Provide Timely Pain Management and Post-Op Care
Penalty
Summary
A deficiency occurred when the facility failed to provide safe and appropriate pain management for a resident following a recent surgical amputation. The resident, who had a history of bilateral lower extremity amputations, diabetes, and other complications, was admitted with orders for pain management and wound care. The care plan included monitoring and documenting pain, as well as interventions for wound management. Despite these plans, the facility did not ensure the resident attended a scheduled post-operative appointment for staple removal due to a failure to arrange transportation. As a result of the missed appointment, the resident experienced ongoing pain and discomfort, with staples remaining in the surgical site. The wound care nurse attempted to remove the staples at the facility after obtaining a verbal order from the vascular clinic, but was unable to remove the last six staples due to the resident's pain. Observations revealed that these remaining staples became embedded in the skin, with crust build-up, and the resident reported persistent pain and concern about possible infection. Staff interviews confirmed that the resident frequently expressed pain related to the embedded staples. The medical director was not initially aware that the resident had missed the post-op appointment or that the staples remained in place, and pain assessments were not effectively communicated to the physician. The facility's policy required ongoing pain recognition and management, but the failure to provide transportation and ensure timely removal of surgical staples resulted in actual harm to the resident, as evidenced by embedded staples and unmanaged pain.
Failure to Arrange Transportation Results in Missed Post-Op Appointment and Harm
Penalty
Summary
The facility failed to arrange transportation for a resident to attend a post-operative medical appointment, resulting in the resident missing a scheduled staple removal following an amputation surgery. The resident, who had a history of major orthopedic surgery, bilateral lower extremity impairment, and pain management needs, was admitted with multiple complex diagnoses including diabetes, atherosclerosis, and surgical site complications. Documentation showed that the resident's appointment was rescheduled without notifying the family, and ultimately canceled due to transportation not being arranged by the facility. The family was not informed of the changes, and the resident reported that transportation was never scheduled. Interviews with staff and review of records revealed that the unit clerk responsible for transportation coordination was aware of the appointment but did not ensure transportation was arranged. The resident experienced pain and reported tightness around the surgical staples, which became embedded due to the missed appointment. The facility did not provide requested documentation of appointment and transportation forms, and the Director of Nursing confirmed that a log should be maintained to track appointments and transportation, which was not effectively done in this case.
Failure to Maintain Antibiotic Stewardship Program
Penalty
Summary
The facility failed to establish and maintain an effective Antibiotic Stewardship program as required by its own policy. Observations and record reviews revealed missing laboratory orders, unresolved dates for antibiotics, lack of documentation on the duration of antibiotic therapy, and inadequate monitoring of residents with infections, particularly those admitted or transferred from hospitals. The Infection Control Book did not contain necessary information to determine true infections, and there was no consistent follow-up on laboratory results or tracking of clinical signs and symptoms related to infections. Interviews with the Infection Preventionist (IP) Nurse confirmed that she did not routinely perform lab follow-up or document resolved dates for antibiotics, and that infections among newly admitted residents were not being tracked or monitored. The Director of Nursing (DON) acknowledged that the IP Nurse was expected to submit weekly listings and follow the facility's policy, and confirmed that missing information could increase the risk of infections not being treated appropriately. The Administrator stated that the DON oversees the Infection Control Program and expected the IP Nurse to adhere to facility policy.
Handrails Blocked by Furniture and Failure to Assess Self-Administration of Medication
Penalty
Summary
Surveyors observed that handrails in both the East Wing and another named wing were repeatedly blocked by dressers, making them inaccessible to residents. These obstructions were noted on multiple occasions over several days, with varying numbers of dressers placed between or beside rooms, directly impeding access to the handrails. Interviews with the Maintenance Director revealed that the obstructions were due to ongoing construction and remodeling of closets, with new wardrobes being delivered and temporarily stored in the hallways. Both the DON and the Administrator confirmed that the handrails were blocked and acknowledged that this interfered with residents' ability to use them for mobility support. Additionally, a deficiency was identified regarding the facility's failure to adequately assess a resident for self-administration of medication. One resident was observed with multiple medications, including triamcinolone acetonide ointment, nystop powder, and milk of magnesia, stored on his nightstand over several days. The resident reported receiving the medications from the hospital and using them regularly for skin issues. However, a review of the electronic medical record showed no physician orders for these medications and no assessment for the resident's ability to self-administer them. The facility's policies require that residents be assessed by the interdisciplinary team and have a physician's order before being allowed to self-administer medications. The DON confirmed that no such assessment or order was present for the resident in question and that staff are expected to monitor for and report medications found in residents' rooms. The lack of assessment and oversight resulted in the resident having access to and using medications without proper authorization or evaluation.
Medication Carts Left Unlocked and Unattended
Penalty
Summary
Staff failed to properly lock and secure three of four medication carts, as required by facility policy and professional standards. Observations revealed that medication carts on the East Wing and [NAME] Wing were left unlocked and unattended while residents were present in the vicinity. In one instance, an LPN left a medication cart unlocked outside the nurse station while she sat behind the station working on a computer, confirming that the cart contained various medications, including psychotropics, diuretics, and narcotics. Another medication cart was left unlocked for 10-15 minutes by a CMA, who was away from the cart and working at the nurse station. Additional observations showed that medication carts were left unlocked and unattended by other staff, including an LPN who left the cart while attempting to access a computer and another LPN who left the cart unlocked while in a resident's room. Interviews with staff and supervisors confirmed awareness of the policy requiring medication carts to be locked at all times when unattended. Staff acknowledged recent in-service training on medication cart security and recognized the potential for residents, staff, or family members to access unsecured medications. Supervisory staff reiterated the expectation that medication carts remain locked when not in direct view of staff, regardless of the duration of absence. Despite this, multiple instances of non-compliance with the policy were observed and confirmed by staff.
Failure to Use Recipe for Pureed Diet Preparation
Penalty
Summary
The facility failed to use a formal recipe when preparing pureed food for residents requiring a pureed diet. During an observation, a food service staff member was seen preparing pureed carrots without referencing a recipe, instead relying on her own experience to determine the amount of carrots and broth to use. The staff member adjusted serving sizes and ingredient amounts without measurement, and added broth by sight rather than by a measured amount. When questioned, she acknowledged that she should be measuring the broth and using a recipe, but did not do so during the observed preparation. The recipe she later produced did not match the number of servings or ingredients used in the preparation. The Dietary Kitchen Manager confirmed that no recipe was followed and that the recipe provided was outdated and not in use, as the facility had changed its menu system and no longer used thickeners. The DKM also acknowledged that not following a recipe could result in incorrect food consistency, which may cause harm to residents. The Administrator stated that kitchen staff are expected to follow recipes to ensure the correct consistency when preparing pureed foods. This deficiency had the potential to affect six residents on a pureed diet.
Deficient Food Storage, Labeling, and Ice Machine Sanitation
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's food storage and handling practices. During observations with the Dietary Manager (DM), several opened food items in the pantry, such as vinegar, peanut butter, quick oats, and creamy wheat, were found without expiration dates. In the cooler, bags of cut cabbage, carrots, spinach, and hot dogs were either not labeled with expiration dates or not labeled at all, with the spinach also noted as wilted. In the freezer, a bag of green peas was not properly sealed. These findings were inconsistent with the facility's policies, which require all food items to be labeled, dated, and properly stored to prevent cross-contamination. Additionally, the ice machine was found to contain debris during an observation and interview with the DM, who stated that the machine is typically cleaned monthly. The Maintenance Director confirmed responsibility for cleaning the ice machine and acknowledged the presence of debris after being shown a photo. Interviews with the DM and Administrator confirmed that staff are expected to label and date food items and that the Maintenance Director is responsible for cleaning the ice machine according to the established schedule. These lapses in following established policies had the potential to affect all residents receiving food orally.
Deficient Infection Surveillance and Improper Laundry Handling
Penalty
Summary
The facility failed to provide proper surveillance and monitoring for infections and communicable diseases for all 114 residents. Review of the Infection Prevention and Control Program policy revealed requirements for ongoing monitoring, documentation, and reporting of infections, but the facility's Infection Control Book was missing infection criteria sheets, accurate data collection, color-coded infection tracking on facility maps, and surveillance records for two months. The Infection Preventionist (IP) Nurse confirmed these deficiencies, acknowledging missing documentation and incomplete monitoring and tracking. The DON and Administrator both stated that the IP Nurse was expected to follow policy and complete the infection control process without missing items, and confirmed that the lack of information could increase the risk of infections not being treated accordingly. Additional observations included improper handling of residents' personal clothing and laundry. A resident's personal clothing was found stored on a unit linen cart, which the Assistant DON confirmed was inappropriate. Furthermore, a Laundry Aide was observed transporting an uncovered laundry cart with clean clothing exposed in the hallways, contrary to infection control practices. The IP Nurse confirmed that clean clothing should be covered during transport and that the housekeeping department was expected to comply with infection control protocols.
Failure to Provide Behavioral Health Training Consistent with Facility Assessment
Penalty
Summary
The facility failed to provide an effective behavioral health training program consistent with its facility assessment and person-centered care requirements. The deficiency was identified through observations, staff and resident interviews, record reviews, and a review of the facility's policy on education and training requirements. The policy stated that training should be based on the needs identified in the facility resource assessment, but evidence showed that staff did not receive adequate training on behavioral health topics relevant to the resident population, including schizophrenia, mental disorders, and PTSD. Three residents with significant behavioral health needs were reviewed. One resident had diagnoses including cerebrovascular disease and schizoaffective disorder/bipolar type, with care plans addressing screaming and verbal outbursts. Another resident had schizophrenia and exhibited verbal aggression, accusations, and suicidal behavior, with care plans and physician orders reflecting these issues. A third resident had mood disorder, PTSD, and cognitive decline, with care plans noting delusions, negative self-feelings, and resistance to care. The facility assessment confirmed that mental disorders, schizophrenia, and PTSD were common diagnoses among residents. Despite these needs, training records revealed only one in-service on managing crisis behaviors and one on behavior management in the past year, with little or no content specific to schizophrenia, mental disorders, or PTSD. Orientation materials for CNAs and other non-nursing staff did not include behavioral health topics. Interviews with CNAs, LPNs, RNs, agency staff, housekeeping, dietary, activities, and other staff consistently revealed a lack of training on behavioral health, schizophrenia, mental disorders, and PTSD. Agency staff and volunteers also did not receive documented behavioral health training. The staff development coordinator and social services director confirmed that training on these topics was infrequent or outdated, and that agency staff were expected to self-educate using binders that lacked relevant materials.
Failure to Maintain Resident Privacy During Personal Care
Penalty
Summary
Staff failed to maintain a resident's dignity and privacy during the provision of personal care. The facility's policy requires that all residents be treated with dignity and respect, and that privacy be maintained by closing the door and pulling the privacy curtain during care. A cognitively intact resident with hemiplegia and significant dependence on staff for activities of daily living, including toileting and bathing, was observed receiving peri-care and assistance with changing while the door to her room was left open. Staff interviews confirmed that the door should have been closed during these activities, and both CNAs involved acknowledged the expectation to maintain privacy by closing the door and pulling the curtain, especially since the resident has a roommate who could enter at any time. The resident herself reported that staff left the door open while providing a bed bath. The Director of Nursing also confirmed that the facility's expectation is for the door to be closed and the privacy curtain pulled during personal care. These actions and inactions resulted in a failure to provide care in a manner that maintained or enhanced the resident's dignity, as required by facility policy and resident rights regulations.
Failure to Maintain Clean and Homelike Resident Room Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment in one resident room located on the East Wing. Facility policy required that walls, blinds, and window curtains be cleaned when visibly soiled, and that staff spot clean walls daily. During observations, brown stains were noted on the wall to the left of the entrance in the identified room. A resident in the room reported that the stains were feces thrown by his roommate and that they had been present for some time. Subsequent observations confirmed that the stains remained on the wall over multiple days. Interviews with housekeeping staff revealed that the assigned aide did not notice or clean the stains, despite her responsibilities including cleaning walls and edges of rooms. The Housekeeping Director confirmed that staff are expected to clean any spots found on the walls. The Administrator also stated that her expectation is for resident walls to be maintained in a clean and sanitary condition. The failure to address the visibly soiled wall resulted in the room not being maintained in accordance with facility policy and resident rights.
Failure to Prevent Misappropriation of Prescribed Narcotics
Penalty
Summary
The facility failed to protect a resident from misappropriation of prescribed narcotics, specifically oxycodone, as required by its Abuse Prevention and Drug Diversion policies. The resident, who was cognitively intact and had significant medical needs including recent amputations and pain management requirements, was prescribed 15 tablets of oxycodone to be administered as needed. Documentation revealed inconsistencies in the administration and accounting of the medication, with only a few doses recorded as given and the remainder unaccounted for. The controlled drug sheet for the medication was missing, and the facility was unable to provide a clear record of the medication's administration or disposition. Interviews with staff and review of records indicated that the required procedures for handling, documenting, and reconciling controlled substances were not followed. Several LPNs provided conflicting or incomplete statements regarding the administration of the medication, and some staff were asked to write statements after the fact, sometimes without clear recollection or supporting documentation. The DON confirmed the absence of the controlled drug sheet and was unable to account for the remaining medication. The pharmacy also reported discrepancies in the order and delivery of the medication. The resident and her family expressed concerns about the missing medication, with the family stating that all 15 pills were gone within three days and doubting that the resident had received all doses. The resident herself recalled taking only three pills and was not informed about the dosing schedule or when the medication would run out. The facility's failure to maintain accurate records, secure the medication, and follow established protocols resulted in the misappropriation of the resident's prescribed narcotics.
Failure to Report Suspected Misappropriation of Narcotics
Penalty
Summary
The facility failed to report a suspected misappropriation of prescription narcotics for one resident to the State Survey Agency (SSA) as required by policy and regulation. The resident, who was cognitively intact and had a history of major orthopedic surgery and pain management needs, was admitted with a hospital discharge order for oxycodone. Documentation showed discrepancies between the number of oxycodone tablets received and administered, with the resident and her family reporting that all 15 pills were gone within three days, despite the resident recalling only taking three pills. The facility was unable to produce the controlled drug sheet for the medication, and the DON confirmed the medication was not in her possession or in the locked box. Interviews with staff, the DON, and the Medical Director revealed a lack of clear documentation and communication regarding the administration and disposition of the narcotic medication. The DON and Administrator both acknowledged that misappropriation of property related to narcotics is a reportable offense, yet the incident was not reported to the SSA. The facility's own policies required investigation and reporting of such incidents, but these procedures were not followed in this case.
Failure to Complete Required PASARR Level II Screenings for Residents with Mental Disorders
Penalty
Summary
The facility failed to obtain a Level II PASARR screening for two residents with mental disorders or intellectual disabilities, as required by its own policy and federal regulations. For one resident, the electronic medical record showed diagnoses including schizoaffective disorder, bipolar type, and a care plan addressing cognitive impairment and behavioral symptoms such as screaming and cursing. This resident was dependent on staff for all ADLs and was prescribed psychotropic medications. Despite these indicators, there was no evidence of a completed Level II PASARR screening prior to or after admission. For the second resident, the record indicated diagnoses of mood disorder due to a physiological condition with mixed features and PTSD, with care plans addressing negative feelings, cognitive decline, and problematic behaviors such as yelling and resistance to care. The social worker and DON both confirmed that a Level II PASARR screening had not been completed for this resident, with the social worker stating she was unaware that PTSD qualified for such screening. Interviews with staff revealed a lack of understanding regarding which diagnoses require a Level II PASARR, and the facility's process did not ensure compliance with its policy or regulatory requirements.
Failure to Provide Required Nail Care for Dependent Resident
Penalty
Summary
Staff failed to provide adequate nail care for a resident who was dependent on staff for personal hygiene due to moderate cognitive impairment and medical conditions including a recent heart attack and metabolic encephalopathy. The facility's policy required staff to supervise and assist with ADLs, including cleaning and trimming nails as needed. The resident's care plan noted a preference for refusing some ADL care, but the resident specifically stated he did not refuse nail care and had requested staff assistance to cut his fingernails. Despite this, observations on multiple occasions revealed the resident's fingernails were long, curled, and had a dark substance underneath. Interviews with staff confirmed awareness of the resident's long nails and the presence of debris, with one CNA stating that nail care should be performed every two weeks and acknowledging the resident's nails had not been properly maintained. The DON stated the resident was care planned for refusals but also confirmed that ADLs, including nail care, should be attempted daily if the resident allows. The failure to provide necessary nail care occurred despite the resident's requests and lack of refusal, resulting in the deficiency.
Failure to Administer Oxygen Therapy per Physician Orders
Penalty
Summary
Staff failed to administer oxygen therapy according to physician orders for two residents receiving oxygen therapy. One resident with chronic obstructive pulmonary disease, atelectasis, and respiratory failure with hypoxia was ordered to receive oxygen at 3 liters per nasal cannula continuously. However, observations showed the oxygen concentrator was set at 4.5 liters and later at 5 liters, exceeding the prescribed rate. The resident was cognitively intact and had a care plan specifying continuous oxygen as ordered by the physician. Another resident with pulmonary embolism and emphysema, who had severe cognitive impairment, was ordered to receive oxygen at 3 liters per mask or cannula continuously. Observations revealed the oxygen concentrator was set at 5 liters, higher than the ordered rate. Multiple staff interviews confirmed that nursing staff are responsible for checking physician orders and ensuring the oxygen concentrator is set to the correct rate, but this was not done for these residents.
Failure to Provide Timely Dental Services for Resident with Oral Pain
Penalty
Summary
The facility failed to provide necessary dental services for one resident who was identified as having a loose tooth and experiencing significant oral pain. According to the facility's Dental Services Policy, routine and emergency dental services should be available based on resident assessments and care plans, with annual and as-needed dental assessments. The resident in question was admitted with hemiplegia and hemiparesis, had moderate cognitive impairment, and required assistance with oral hygiene. The care plan and physician's orders indicated the need for dental evaluation and treatment as indicated. Despite these documented needs, the resident's oral assessments repeatedly noted a loose tooth, but the section indicating whether a referral to a dentist was needed was left blank. The resident reported daily to nursing staff about severe tooth pain and the need for extraction, but no referral was made. Multiple interviews with staff confirmed that the process for dental referrals was not followed: the nurse did not complete the referral section of the assessment, and the Social Services Director was not notified of the need for a dental consult. The resident continued to experience pain and had not seen a dentist since admission. Staff interviews revealed a lack of awareness and communication regarding the resident's dental needs. CNAs reported oral concerns to nurses, but the nurses did not act on the information by initiating a referral. The Social Services Director and unit manager confirmed that the resident qualified for Medicaid dental benefits and should have been referred to the in-house dental program, but this did not occur. The Director of Nursing and Administrator acknowledged that the failure to make a timely dental referral could result in negative outcomes, and confirmed that the required process for dental referrals was not followed for this resident.
Failure to Ensure Accessible and Functional Call System for Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of falls was not provided with a functional and accessible call system in their room. During an observation, a registered nurse repeatedly instructed the resident not to use the call device, stating that the resident was pressing it frequently for a snack. The nurse was observed leaving the room after making these statements. The call system cord was later found extracted from the wall, rendering it nonfunctional. Interviews with the resident's roommates confirmed that the nurse had told the resident to stop pressing the call light. The nurse acknowledged that staff are not supposed to keep the call device away from the resident but explained her actions by stating the resident had already received a snack. The resident's medical record indicated severe cognitive impairment, dependence on staff for activities of daily living, and a care plan that encouraged the use of the call bell for assistance. Facility policy required that call lights be answered promptly and remain accessible to residents. The Director of Nursing confirmed that all call lights should remain in place and that staff should not instruct residents not to use the call device. The failure to ensure the call system was accessible and functional for this resident constituted a deficiency.
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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