Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Buckhead Center For Nursing And Healing during CMS and state inspections, most recent first.
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.
Improperly Labeled and Dated Refrigerated Food Items: Surveyors found multiple unlabeled and undated food items in the reach-in refrigerator, including salad, dessert, and iced tea. The DM confirmed the findings and stated kitchen staff had been educated on labeling and dating opened or stored items, with responsibility resting on the person who placed the items in the refrigerator.
Failure to monitor significant weight loss affected three residents. One resident with severe cognitive impairment and diagnoses including peripheral vascular disease and schizophrenia lost 203 lbs. to 157 lbs. in about a month, but weekly weights were not obtained despite RD notes and facility policy. Another resident with dysphagia, malnutrition, obesity, and Alzheimer’s disease had significant weight loss documented, yet the record did not show weekly weights or clear PAR follow-up. Staff interviews confirmed that weekly weights were expected after significant loss, but they were not completed.
Failure to maintain resident dignity during meal assistance and in a resident room. An LPN stood next to a resident with moderate cognitive impairment while feeding him lunch instead of sitting across from him, and later an LPN/UM confirmed this was a dignity issue. In a separate incident, a CNA used a personal cell phone in a resident room occupied by two residents; the UM overheard the loud voice, the CNA acknowledged answering the call, and one resident said it was disrespectful.
Failure to Invite Cognitively Intact Residents to Care Plan Meetings: The facility failed to ensure two cognitively intact residents were invited to participate in their quarterly care plan meetings. One resident’s EMR had no evidence of an invitation, and the resident stated she was not invited; the DSS confirmed only the representative was invited. For the other resident, the EMR showed no indication of invitation or participation, the resident said he knew nothing about meetings, and the SSA could not provide invitation letters for two quarterly meetings. The DON stated residents were to be invited so they could participate in developing the care plan.
A resident with moderate cognitive impairment repeatedly requested a salad with meals, but staff did not provide it on multiple observed lunch trays. The resident’s meal tickets showed the salad request, a CNA and an LPN confirmed the salad was missing, and the DM stated he forgot to add the salad to the resident’s trays.
Failure to Follow Glucometer Disinfection and Hand Hygiene Practices: An LPN did not perform hand hygiene or disinfect a glucometer before or after a BG check and insulin administration for a resident, placing the device on the bedside table and returning it to the MC without cleaning it. The facility also failed to perform hand hygiene during wound care for another resident with HIV and arterial foot wounds, as an LPN changed gloves between wound sites without sanitizing hands; both the LPN and RN acknowledged the lapse.
A resident with stroke, tracheostomy, and gastrostomy status, who was dependent for all ADLs and rarely/never understood on BIMS, had a care plan directing staff to keep the call light within reach. Staff repeatedly left the call pad in locations the resident could not reach while he was in bed receiving tube feeding. The resident could not press the call pad when asked, and an LPN and the DON acknowledged the call light needed to be positioned for the resident to use it.
Inadequate ADL Hygiene Care: A resident with hemiparesis, hemiplegia, dementia, and low vision was dependent for oral hygiene, dressing, toileting hygiene, and bathing, yet surveyors observed a dark brown substance under his fingernails on two occasions. The RP reported staff did not bathe him and had seen dirt buildup around his neck and dirty fingernails, while an NM and an LPN confirmed the fingernails should have been cleaned.
Insulin Administration Errors: The facility failed to keep two residents with diabetes free from significant med errors involving insulin. An LPN gave one resident’s Lispro dose earlier than ordered after a BG check, and the record showed many other insulin doses were given late for that resident. For another resident, multiple Glargine and Lispro doses were also given late. The record lacked documentation that the provider was notified or that either resident was monitored for hypo- or hyperglycemia.
The facility failed to maintain cold food at the required temperature, with coleslaw observed at 50°F during lunch service. The Dietary Aide prepared multiple bowls without using ice, contrary to policy, potentially affecting 142 residents.
A Business Office Manager, whose CNA certification had expired, was observed providing ADL care by shaving a resident with hemiplegia and moderate cognitive impairment. The BOM acted outside her job scope without family permission, highlighting a deficiency in staff training and competency assurance.
Two residents with quadriplegia and pressure ulcers did not receive consistent care in a facility, leading to the progression of ulcers. One resident's care plan initially lacked repositioning interventions, and staff failed to regularly reposition him or apply pressure-relieving devices. The other resident, severely cognitively impaired, was not repositioned as required, with no documentation of care. Staff interviews revealed a lack of adherence to standard practices, resulting in harm to the residents.
Two residents in an LTC facility were affected by the misappropriation of 49 oxycodone pills, which were unaccounted for during a narcotic count. The facility's policy requires discrepancies to be resolved or reported immediately, but this was not followed. One resident had nine pills missing, while another had 40 pills missing. An LPN admitted to concealing the discrepancy by folding the drug record page. The issue was reported by the Unit Manager, leading to an investigation by the DON.
A facility failed to develop comprehensive care plans for a resident prescribed high-risk medications, including an anticoagulant and an antidepressant. Despite policies requiring care plans with specific goals and interventions, none were created for the resident, who had a history of blood clots and depression. Interviews confirmed the oversight, revealing a lapse in the process for initiating care plans for high-risk medications.
A resident with quadriplegia and contractures did not receive consistent application of knee splints to maintain range of motion (ROM) due to staff's lack of knowledge and comfort in applying them. Despite being discharged from physical therapy with instructions for continued splint use, observations showed the splints were not applied, and staff interviews revealed uncertainty about their use. The resident was willing to comply with interventions, but the facility's failure to apply the splints consistently led to a deficiency in care.
A resident with pneumonia and severe cognitive impairment required nebulizer treatments, but the facility failed to store the nebulizer mask properly, leaving it uncovered on the nightstand. Despite the facility's policy and staff training, the mask was not placed in a bag to prevent contamination, as confirmed by staff interviews.
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.
Improperly Labeled and Dated Refrigerated Food Items
Penalty
Summary
The facility failed to properly label and date several food items in the refrigerator. During a kitchen flash tour, surveyors found two plates of salad, 12 small containers or bowls of dessert, and 16 small glasses of iced tea in the reach-in refrigerator that were not labeled or dated. The Dietary Manager was present and confirmed the findings. In an interview, the Dietary Manager stated that kitchen staff had been educated on labeling and dating all opened or stored items in the refrigerator and explained that whoever placed the items in the refrigerator was responsible for labeling and dating them.
Failure to Monitor Significant Weight Loss
Penalty
Summary
The facility failed to monitor and follow up on significant weight loss for three residents, despite its policy requiring weight monitoring, weekly weights for residents with weight loss, and comparison of each new weight to the previous recorded weight. The policy also defined significant weight loss as 5% in 1 month, 7.5% in 3 months, or 10% in 6 months. Survey review found that the facility did not consistently obtain weekly weights or document follow-up when residents met these thresholds. One resident had diagnoses including peripheral vascular disease, paranoid schizophrenia, and vitamin D deficiency, and had severe cognitive impairment with a BIMS score of 4. The resident’s weight decreased from 203 lbs. to 157 lbs. in about one month, with a reweigh showing a 19.7% loss. A nutrition note indicated the resident should be reweighed and the RD would monitor and follow up, and later dietary notes said labs would be obtained and the resident would be added to the weekly weights sheet. However, weekly weights were not obtained. During interviews, the RD stated the resident wanted to lose weight, that labs were requested because of the amount of loss, and that nursing staff were to conduct weekly weights, which were not done. Another resident had diagnoses including dysphagia, unspecified protein-calorie malnutrition, obesity, and Alzheimer’s disease, with moderate cognitive impairment and a BIMS score of 9. The resident had unplanned weight loss documented in the care plan, and weights showed a loss of 9.0 lbs. (5.65%) in 30 days. The record did not show weekly weights after the significant loss, and the PAR note did not include direction to reweigh or obtain weekly weights. The RD noted the resident had significant weight loss and that nursing was to weigh per protocol, while unit management and the DON stated weekly weights should have been obtained after the weight loss was identified.
Failure to Maintain Resident Dignity During Meal Assistance and in a Resident Room
Penalty
Summary
The facility failed to provide a dignified dining experience for R15. R15’s EMR showed he was admitted to the facility and had a quarterly MDS with a BIMS score of 12 out of 15, indicating moderate cognitive impairment; the assessment also showed he required set up assistance with meals. During an observation in the main dining room, an LPN stood next to R15 while assisting him with lunch, repeatedly giving him bites of food while standing rather than sitting across from him, and then left the area after several minutes. The LPN later confirmed he had been standing while feeding R15 and stated he should have sat across from the resident to assist with the meal. The facility also failed to maintain dignity when CNA3 used a personal cell phone in a resident room occupied by R15 and R80. During a medication pass observation, CNA3 was overheard speaking loudly behind the closed door and was found on her cell phone after the door was opened. The UM confirmed hearing CNA3’s loud voice and stated that staff using a personal cell phone in a resident room was a dignity issue. CNA3 acknowledged she had answered her phone because her child called and stated she should not have been on the phone in the resident room. R80 stated the incident was disrespectful, and the DON later stated that both the standing meal assistance and the cell phone use in a clinical setting were dignity issues.
Failure to Invite Cognitively Intact Residents to Care Plan Meetings
Penalty
Summary
The facility failed to ensure that two residents, R5 and R37, were invited to participate in their quarterly care plan meetings. For R5, the EMR did not contain evidence that she was invited to her quarterly care conferences. R5 stated she did not get invited, and the DSS confirmed that only R5’s representative was invited, not R5 herself. The DSS later stated there were no prior quarterly care conferences identified for R5 in the EMR and confirmed that R5 was her own representative. The DON stated residents were to be invited to their care conferences so they could participate in the development of the care plan. The facility policy titled Comprehensive Care Plans, dated March 2025, stated the comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive assessment and quarterly MDS. For R37, the EMR showed diagnoses of COPD, epilepsy, and diabetes, and an annual MDS with a BIMS score of 15 out of 15, indicating intact cognition. However, the EMR contained no indication of invitation or participation in any care plan conference meetings. When asked about quarterly meetings, R37 stated, “I don't know anything about meetings.” The Administrator stated the invitations were in the medical records but had not been scanned into the EMR yet. The SSA stated residents were given letters inviting them to their meetings, but could not provide invitations for the 6/3/2025 and 8/1/2025 meetings for R37.
Resident Food Preferences Not Honored
Penalty
Summary
The facility failed to ensure that food preferences were honored for one resident, R49, who requested a salad with lunch and dinner and wanted this regularly. The facility policy stated that each resident is to be provided a nourishing, palatable, well-balanced diet that meets daily nutritional and special dietary needs while taking into consideration resident preferences. R49’s EMR showed the resident was admitted to the facility on [DATE] and had a quarterly MDS with a BIMS score of 10 out of 15, indicating moderate cognitive impairment. During an interview on 9/22/2025, R49 stated she had requested a salad for lunch and dinner. At 12:44 PM that day, a CNA confirmed that R49’s lunch tray did not have a salad, and the resident’s meal ticket showed that she had requested a salad per meal. On 9/23/2025 at 12:48 PM, an LPN confirmed that R49 again did not have a salad on her lunch tray, and the resident presented a copy of her meal ticket dated 9/23/2025. On 9/25/2025 at 8:29 AM, the Dietary Manager confirmed that R49 had requested salads with her meals and that he forgot to add the salad to the resident’s trays.
Failure to Follow Glucometer Disinfection and Hand Hygiene Practices
Penalty
Summary
The facility failed to follow its glucometer disinfection policy and hand hygiene practices during a blood glucose check and insulin administration for one resident. The facility policy titled "Glucometer Disinfection" required glucometers to be cleaned and disinfected after each use and according to manufacturer instructions, with hand hygiene performed before and after glove use. During a medication administration observation on 9/22/2025, an LPN prepared a blood glucose check for R131, placed the glucometer and supplies in his scrub pocket, brought the glucometer to the resident's bedside table without a barrier, and did not perform hand hygiene before donning gloves. The LPN did not disinfect the glucometer before or after use, performed the blood glucose check, administered 4 units of Lispro insulin, removed gloves, returned to the medication cart, and placed the glucometer back in the cart drawer without disinfecting it. The LPN stated he should have performed hand hygiene and disinfected the glucometer but did not. The report also identified that the facility had residents with HIV and hepatitis C who were receiving blood glucose checks and insulin injections, and the DON confirmed those residents had individual glucometers stored in the medication cart. During review with the DON, the facility's glucometer manufacturer instructions and bleach wipe directions were discussed, including the required contact times for disinfection. The DON confirmed staff should follow the manufacturer's instructions and the bleach wipe package directions. The facility also failed to perform hand hygiene during wound care for R59. R59's record showed diagnoses including HIV disease and anemia, a BIMS score of 13 out of 15, and three venous/arterial ulcers present on admission. Wound care orders directed cleansing and dressing of arterial wounds on both feet. During wound care observation on 9/23/2025, an LPN did not perform hand hygiene after changing gloves between care of the left and right foot wounds and during dressing application. Both the LPN and the RN observing the care acknowledged that hand hygiene was not performed between glove changes, and the RN stated this could increase the risk of wound infection.
Call Light Not Kept Within Reach for Dependent Resident
Penalty
Summary
The facility failed to ensure the call light was accessible for one resident who was dependent on staff for all ADLs and had impaired range of motion on one side of the upper and lower extremities. The resident’s record showed diagnoses including stroke affecting the left non-dominant side, tracheostomy status, and gastrostomy status. The quarterly MDS indicated the resident was rarely or never understood. The care plan directed staff to encourage the resident to use a bell to call for assistance and to keep the call light within reach because of ADL self-care deficits and fall risk related to impaired mobility and poor safety awareness. During multiple observations, the resident was lying in bed receiving tube feeding, with the bed positioned against the right-side wall and a floormat on the left side. The call pad/light was repeatedly observed in locations the resident could not reach, including resting on an oxygen machine on top of a bedside table behind the headboard and later on the top left corner of the bed. A roommate stated staff had placed the call light there the prior evening. When asked to reach and press the call pad, the resident could not do so and could not speak because of the tracheostomy. An LPN stated the call pad should be placed under the resident’s head or body, and the DON stated the resident could not press the call pad by hand and staff should attach it to the resident’s head to function properly.
Inadequate ADL Hygiene Care
Penalty
Summary
The facility failed to provide adequate ADL care for one resident, identified as R128, who was unable to perform these tasks independently. R128’s record showed diagnoses including hemiparesis and hemiplegia, major depressive disorder, low vision in the left eye, and dementia. The MDS indicated he required supervision for eating, substantial to maximum assistance for bed mobility, and was dependent for oral hygiene, dressing, toileting hygiene, and bathing. The facility’s ADL policy stated that care and services must be provided to ensure a resident’s abilities in ADLs do not diminish unless unavoidable due to clinical condition. During observations, R128 was seen with a dark brown substance under his fingernails on two separate occasions. R128 stated he received bed baths on a regular basis, but his responsible party reported that staff did not bathe him and had observed dirt buildup around his neck and dirty fingernails. The Nurse Manager stated fingernails should be cleaned thoroughly during showers or baths and as needed between them, and an LPN observed the fingernails and stated, "They need to be cleaned."
Insulin Administration Errors
Penalty
Summary
The facility failed to ensure two residents with diabetes were free from significant medication errors related to insulin administration. The report states that the facility’s policy required medications to be given in accordance with the prescriber’s order and identified medication errors as doses, routes, dosage forms, or times that did not match the order. It also stated that significant medication errors are those that cause discomfort or jeopardize health and safety. For one resident with type 1 diabetes and long-term insulin use, the record showed multiple insulin orders, including Lispro sliding scale, Lispro twice daily, and Lantus at bedtime and in the morning. During observation, an LPN checked the resident’s blood glucose at 9:51 AM, found it was 245, and administered the 11:30 AM Lispro dose at 9:55 AM, earlier than the ordered time. The LPN stated he gave it early because the electronic system showed green and allowed administration. The resident stated later that no staff rechecked his blood glucose after the insulin was given and that he did not receive snacks afterward. The record review also showed numerous late insulin administrations for this resident across several orders, including sliding scale Lispro, scheduled Lispro, and Lantus, with examples ranging from minutes late to many hours late. For the second resident with type 2 diabetes, the record review showed late administration of insulin Glargine and Lispro on multiple occasions while the resident was on those orders. Examples included doses due at 9:00 PM, 12:00 PM, and 5:00 PM that were administered hours later. The record contained no documentation that staff notified the provider when insulin was given early or late, and there was no documentation that the resident was monitored for hyperglycemia or hypoglycemia. The RDCS and DON stated that insulin given more than one hour early or late was considered a medication error and that the provider should be notified and the resident monitored and documented.
Cold Food Temperature Control Deficiency
Penalty
Summary
The facility failed to maintain the required temperature for cold food, specifically coleslaw, which was observed to be above the safe temperature threshold. During a lunch service, the Dietary Manager (DM) noted that the prepared bowls of coleslaw registered at 50 degrees Fahrenheit, which is above the maximum safe temperature of 41 degrees Fahrenheit. This was contrary to the facility's policy that mandates cold food to be held at 41 degrees Fahrenheit or colder to prevent the growth of pathogens that cause foodborne illnesses. The Dietary Aide (DA) had prepared multiple bowls of coleslaw without placing them on ice, which contributed to the temperature rise. Although the DM stated that the coleslaw temperature was initially below 40 degrees Fahrenheit before service, the DA did not follow the procedure of preparing one bowl at a time or using ice to maintain the temperature. This oversight had the potential to affect 142 of the 153 residents receiving an oral diet at the facility.
Unqualified Staff Member Provides ADL Care
Penalty
Summary
The facility failed to ensure that clinical staff were trained and competent to provide Activities of Daily Living (ADL) care, as evidenced by an incident involving the Business Office Manager (BOM) providing such care to a resident. The BOM, whose certification as a Certified Nursing Assistant (CNA) had expired, was observed shaving a resident with hemiplegia, hemiparesis, and moderate cognitive impairment. The resident required substantial/maximal assistance for ADLs, and the BOM was not authorized to perform this task as it was outside her job scope. The BOM admitted to shaving the resident because he was her friend and had requested it, despite not having permission from the resident's family. The facility's Administrator confirmed that the BOM should not have been performing this task, as it was not within her responsibilities and she was not a certified CNA. This incident highlights a deficiency in the facility's training and competency assurance for staff, potentially affecting the care of all residents.
Inconsistent Pressure Ulcer Care Leads to Harm
Penalty
Summary
The facility failed to provide consistent care and services for two residents, R56 and R63, who were at risk for pressure ulcers. R56, who was admitted with quadriplegia and existing pressure ulcers, did not have turning and repositioning documented as an intervention in his care plan until after his ulcers progressed to a Stage 4 and an unstageable wound. Observations and interviews revealed that R56 was not regularly repositioned, and staff were inconsistent in applying pressure-relieving devices such as heel boots. Despite the presence of an air mattress and wedges, there was no documentation of regular repositioning, and staff interviews indicated a lack of adherence to a consistent repositioning schedule. R63, also diagnosed with quadriplegia and severe cognitive impairment, had pressure ulcers upon admission that were not adequately managed. The care plan indicated the need for turning and repositioning, but observations showed that R63 was not repositioned for extended periods, and there was no documentation of repositioning in the Plan of Care. Interviews with staff, including the Director of Nursing and the MDS Nurse, confirmed that repositioning every two hours was a standard practice, yet this was not consistently implemented or documented for R63. The lack of consistent implementation and documentation of repositioning and the use of pressure-relieving devices for both residents led to the development and worsening of pressure ulcers. Staff interviews revealed a reliance on verbal communication and informal practices rather than documented care plans, contributing to the deficiency in care. The facility's failure to adhere to standard practices for pressure ulcer prevention and management resulted in harm to the residents, as evidenced by the progression of R56's ulcers and the inadequate care for R63's existing wounds.
Misappropriation of Narcotics in LTC Facility
Penalty
Summary
The facility failed to protect two residents from the misappropriation of their medications, specifically oxycodone, when 49 pills were unaccounted for during a narcotic count. The facility's policy on Controlled Substance Administration and Accountability requires that any discrepancies in the count of controlled substances be resolved by the end of the shift or reported immediately if unresolved. However, this protocol was not followed, leading to the misappropriation of medications for two residents. The first resident, R115, was admitted with conditions including lymphedema and chronic peripheral venous insufficiency. The resident was cognitively intact and had a care plan focusing on pain management, which included the administration of oxycodone as needed. A review of the controlled drug record revealed that nine oxycodone tablets were missing. The second resident, R226, had a history of Alzheimer's Disease and chronic ulcers, with a care plan addressing chronic pain. The controlled drug record indicated that 40 oxycodone tablets were missing. The investigation revealed that LPN5, a contracted agency staff member, was responsible for counting the narcotics but failed to report the missing medications at the beginning of her shift. She admitted to folding the controlled drug record page to conceal the discrepancy. LPN4, the Unit Manager, discovered the missing medications and reported the issue to the DON, who initiated an investigation. Interviews with involved staff confirmed the misappropriation, but attempts to interview LPN6 and LPN8 were unsuccessful.
Failure to Develop Comprehensive Care Plans for High-Risk Medications
Penalty
Summary
The facility failed to develop comprehensive care plans with resident-specific goals and interventions for a resident who was prescribed high-risk medications, including an anticoagulant and an antidepressant. The facility's policies on High-Risk Medications - Anticoagulants and Comprehensive Care Plans require that care plans include interventions to minimize adverse consequences and measurable objectives to meet the resident's needs. However, a review of the electronic medical record (EMR) for the resident revealed that no care plan had been developed for the use of these medications, despite the resident having a history of venous thrombosis and embolism and a diagnosis of depression. Interviews with the Director of Nursing (DON) and the MDS Coordinator confirmed the oversight. The DON verified that the care plan did not include specific goals and interventions for the medications, while the MDS Coordinator explained that the process involves reviewing an action printout for MDS and nurses to verify and implement a plan of care. The MDS Coordinator acknowledged that the need for a care plan was overlooked, indicating a lapse in the facility's process for ensuring that care plans are initiated for high-risk medications.
Failure to Apply Knee Splints for Resident with Quadriplegia
Penalty
Summary
The facility failed to consistently apply knee splints for a resident with quadriplegia and contractures, leading to a deficiency in maintaining the resident's range of motion (ROM). The resident, who was dependent on staff for all Activities of Daily Living (ADL) care, had been discharged from physical therapy with instructions for the nursing staff to continue using knee splints to maintain ROM. However, observations revealed that the splints were not being applied, and interviews with staff indicated a lack of knowledge and comfort in applying the splints. The resident's care plan included interventions for maintaining ADL functions, but the necessary application of knee splints was not consistently executed. Interviews with the Certified Nursing Assistant (CNA) and Licensed Practical Nurse (LPN) revealed that staff were unsure about the use of the assistive devices and lacked proper training or assistance from the therapy department. The Rehab Director confirmed that the nursing team was provided with the knee splints and education on their application, but the staff did not feel comfortable applying them. The resident expressed willingness to comply with interventions to prevent contractures and denied declining care, contradicting staff claims. Despite the Rehab Director's confirmation that the splints were effective in slowing contracture progression, the facility's failure to apply them consistently resulted in a deficiency in care for the resident.
Improper Storage of Nebulizer Mask
Penalty
Summary
The facility failed to properly store a nebulizer mask to prevent cross-contamination for a resident who required respiratory care. The facility's policy on nebulizer therapy, revised in March 2023, mandates that the nebulizer cup and mouthpiece be stored in a zip lock bag once dry. However, observations on two consecutive days revealed that the resident's nebulizer mask was left uncovered on the nightstand next to the nebulizer machine. Interviews with staff confirmed that the mask should have been stored in a bag when not in use, as per the facility's policy. The resident in question was admitted with a diagnosis of pneumonia and required nebulizer treatments for shortness of breath. The resident was severely cognitively impaired, as indicated by a score of zero on the Brief Interview for Mental Status. Despite the facility's policy and training provided to the nursing staff, the nebulizer mask was not stored properly, and the night shift nurse failed to change the tubing and mask or place it in a bag. The Director of Nursing and the Director of Respiratory Services acknowledged the oversight, noting that the mask and tubing should be changed weekly and stored in a bag to prevent contamination.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Atlanta
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westminster Commons | 1.3 mi | ★★★★★ | 0 | 0 |
| Terraces At Peachtree Hills Place, The | 2.1 mi | ★★★★★ | 5 | 0 |
| Pruitthealth - Virginia Park | 2.5 mi | ★★★★★ | 0 | 0 |
| A.g. Rhodes Home, Inc, The | 3.1 mi | ★★★★★ | 8 | 0 |
| Legacy Transitional Care & Rehabilitation | 3.1 mi | — | 9 | 0 |
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