Calhoun Crossing Of Journey Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Calhoun, Georgia.
- Location
- 1387 Highway 41 North, Calhoun, Georgia 30701
- CMS Provider Number
- 115340
- Inspections on file
- 15
- Latest survey
- August 28, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Calhoun Crossing Of Journey Llc during CMS and state inspections, most recent first.
The facility failed to implement comprehensive care plans for three residents, leading to deficiencies in fall prevention and care planning. One resident's care plan did not address his desire for prostheses, another resident's bed was not kept in a low position as required, and a third resident fell due to inadequate staff assistance during incontinence care. These oversights were acknowledged by facility staff, highlighting a breakdown in care plan implementation.
A resident with bilateral above-the-knee amputations did not receive the necessary follow-up for prostheses fitting, despite being evaluated as ready and expressing a strong desire for independence. The facility failed to arrange the required appointments, leading to the resident's emotional distress. Interviews with staff revealed communication lapses and a lack of follow-through on the resident's care plan.
Two residents experienced falls due to inadequate supervision and failure to adhere to care plans. One resident, requiring two-person assistance, fell and was injured when a CNA provided care alone. Another resident, with a care plan requiring a low bed position, fell when the bed was not maintained in the correct position. Staff interviews confirmed these deficiencies.
The facility's QAPI plan was incomplete, lacking specific facility information and data-driven measures to address resident care and safety. The plan did not include tracking, trending, or performance measurements on clinical concerns, nor did it show feedback from staff, residents, or family members. The Administrator confirmed the plan was sourced online, potentially affecting all 91 residents.
The facility failed to complete accurate PASARR assessments for two residents. One resident's PASARR was outdated, and another's inaccurately reflected their mental health diagnoses, despite documented conditions such as PTSD and major depressive disorder. The facility's policy lacked guidance on addressing inaccurate PASARRs, contributing to these deficiencies.
The facility failed to include required language in its arbitration agreements for two cognitively intact residents, indicating that signing was not mandatory for admission or continued care. The Business Office Manager confirmed the omission during an interview, revealing a lack of awareness of this requirement.
The facility failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to two residents, preventing them or their representatives from making informed decisions about financial liabilities for services not covered by Medicare. The residents remained in the facility after their skilled services ended without receiving the necessary notices, as confirmed by the Administrator.
The facility failed to provide written notification of hospital transfers for three residents, as required by federal regulations. The deficiency was due to the absence of a policy ensuring written notices were given to residents or their representatives. This was confirmed through interviews with the Administrator and DON, who acknowledged the lack of enforcement of this requirement.
The facility failed to provide written notification of its Bed Hold Policy to residents or their representatives prior to hospital transfers. Three residents were hospitalized without documented evidence that the policy was communicated in writing, despite the facility's policy requiring it. The administrator confirmed the absence of documentation, indicating non-compliance with the policy.
A facility failed to refer a resident for a Level II PASARR evaluation after a new diagnosis of major depressive disorder. Despite the facility's policy requiring such referrals for newly evident serious mental disorders, no PASARR Level II was submitted following the diagnosis. The resident was initially admitted without this diagnosis, but later evaluations and care plans indicated the presence of major depressive disorder and the use of antidepressant medication.
A resident receiving enteral nutrition via a PEG tube had their feeding bag improperly labeled, lacking essential information such as date, time, and resident's name. The LPN on duty confirmed the oversight, attributing it to the night shift nurse. Interviews revealed a lack of accountability and adherence to the facility's policy, which mandates proper labeling for safety and compliance with clinical standards.
The facility failed to provide timely access to personal funds for three residents due to restricted banking hours, limited to weekdays from 9:00 AM to 3:00 PM. Residents expressed a desire for weekend access, which was previously available but had been discontinued. Interviews with staff confirmed the lack of access outside these hours, despite the Administrator's expectation for reasonable access.
The facility failed to provide quarterly financial statements to two residents, one cognitively intact and one mildly impaired, whose funds were managed by the facility. The Medical Records Director sent statements to resident representatives instead, contrary to the Administrator's expectation for capable residents to receive their own statements.
The facility failed to release funds from Personal Needs (PN) Accounts to residents or their Responsible Parties (RP) within the federally mandated 30 days after discharge. This deficiency affected three residents who had passed away, with balances remaining in their accounts for several months. Interviews with facility staff confirmed the oversight, with no clear explanation provided for the delay.
Two residents with Type 2 Diabetes experienced medication administration errors involving insulin pens, resulting in a 6.06% error rate. One LPN failed to leave the needle in the skin for the required time, while another did not prime the pen needle before administration. Both actions were contrary to the facility's insulin policy.
The facility failed to maintain effective infection control for two residents. One resident, COVID-19 positive, was not properly isolated as staff entered without PPE, despite clear droplet precaution signage. Another resident's catheter tubing was observed on the floor, risking infection. The facility's policies on isolation and catheter care were not followed, leading to these deficiencies.
The facility failed to administer pneumococcal vaccines according to CDC guidelines for two residents over the age of 65. One resident received the PCV15 vaccine but was not offered the PPSV23 within the recommended timeframe, while another received the PPSV23 but was not offered the PCV15 or PCV20. The RN responsible did not transfer the due dates to her tracking log, leading to the oversight. The interim IP and DON were unaware of these lapses, and the Administrator expected timely vaccine administration.
Deficiencies in Care Planning and Fall Prevention
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for three residents, leading to deficiencies in fall prevention and care planning. For one resident with bilateral above-the-knee amputations, the care plan did not address his desire for bilateral prostheses and independence with ambulation, despite his goal to return home. The facility's care plan only focused on coping skills for limb loss, neglecting the resident's expressed wishes. Another resident, diagnosed with Alzheimer's Disease and severely cognitively impaired, was at risk for falls due to balance problems and lack of safety awareness. The care plan required the bed to be in the lowest position to prevent falls, but observations revealed the bed was consistently at regular height. This oversight was acknowledged by the facility's Administrator and DON, who confirmed that care plans should be followed as documented. A third resident, with hemiplegia and morbid obesity, required two-person assistance for incontinence care. However, a CNA, unaware of this requirement, attempted to provide care alone, resulting in the resident falling out of bed and sustaining a broken finger. The CNA admitted to not reviewing the care plan or receiving proper training, and the DON confirmed the fall was due to the care plan not being followed. The MDSC verified that the care plan was accessible to all CNAs, indicating a communication breakdown in care plan implementation.
Failure to Provide Prostheses for Resident with Bilateral Amputations
Penalty
Summary
The facility failed to provide appropriate adaptive equipment as directed by Physical Therapy recommendations for a resident with bilateral above-the-knee amputations. The resident, who was cognitively intact, had been admitted with diagnoses including diabetes and required supervision for bed mobility and transfers. Despite making consistent progress in physical therapy and being evaluated as ready for prostheses, the facility did not ensure the resident received the necessary follow-up appointments for fitting the prostheses. The resident had been evaluated by a Certified Prosthetist/Certified Orthotic Assistant, who confirmed the resident's readiness for bilateral prostheses. However, there was no evidence in the clinical record that a follow-up appointment was made to fit the resident with the prostheses. The resident repeatedly expressed his need for the prostheses to promote his independence, and his emotional distress was noted by staff and during interviews. Interviews with facility staff, including the Director of Rehabilitation and Nurse Practitioners, revealed a lack of communication and follow-through regarding the resident's prostheses. The facility's scheduler, responsible for arranging community appointments, was on leave, contributing to the oversight. The resident's emotional state was affected by the delay, as he was eager to regain independence and return home with the use of prostheses.
Failure to Prevent Falls Due to Inadequate Supervision and Care Plan Adherence
Penalty
Summary
The facility failed to prevent a fall for two residents, R10 and R47, resulting in harm to R10. R10, who was moderately cognitively impaired and required assistance from two staff members for incontinence care, fell off the bed when a CNA provided care alone. The CNA was unaware of the two-person assistance requirement and did not review R10's care plan. This resulted in R10 suffering a closed head injury, a laceration to the forehead, and a fracture of the fifth finger on the right hand. R47, who was severely cognitively impaired and required assistance for transfers, experienced an unwitnessed fall while attempting to transfer from bed to wheelchair. The care plan for R47 included keeping the bed in the lowest position to prevent falls. However, observations revealed that the bed was not consistently kept in the low position, and there was no sign to remind staff of this requirement. The failure to maintain the bed in the correct position contributed to the fall. Interviews with staff and family members confirmed the deficiencies in following care plans for both residents. The CNA involved in R10's care was not informed of the two-person assistance requirement, and the staff responsible for R47's care did not ensure the bed was kept in the low position. The facility's policies on fall prevention and adherence to care plans were not effectively implemented, leading to these incidents.
Incomplete QAPI Plan Lacks Data-Driven Measures
Penalty
Summary
The facility failed to develop a comprehensive Quality Assurance Performance Improvement (QAPI) plan that effectively addressed resident care, safety, quality of life, and resident choice. The QAPI plan, dated 2022 and prepared by Compliance Store, was intended to establish a data-driven, facility-wide program to improve the quality of care and services. However, the plan was found to be incomplete, lacking specific facility information and failing to address potential quality of care issues. Notably, the plan did not include data-driven information such as tracking and trending, or performance measurements on specific clinical concerns. Additionally, the facility's QAPI plan did not demonstrate any feedback from staff, residents, or family members regarding identified potential deficient practices. During an interview, the Administrator acknowledged presenting the QAPI plan to the survey team and confirmed that the plan was printed from an online source. This lack of a detailed and facility-specific QAPI plan had the potential to affect all 91 residents currently living in the facility.
Failure to Complete Accurate PASARR Assessments
Penalty
Summary
The facility failed to complete the required Pre-Admission Screening and Resident Reviews (PASARR) for two residents, leading to deficiencies in their care. For one resident, identified as R31, the PASARR Level I was dated over 30 days before the resident's admission, which did not meet the facility's expectation to complete a new PASARR if the previous one was outdated. The resident was currently receiving mental health services, indicating the need for an updated assessment. For another resident, identified as R64, the PASARR Level I inaccurately indicated the absence of a major mental illness diagnosis, despite the resident having documented diagnoses of PTSD, anxiety disorder, and major depressive disorder. The resident's care plans and physician orders reflected these conditions, and the Director of Nursing confirmed the inaccuracy of the PASARR. The facility's policy did not address the responsibility for correcting inaccurate PASARR assessments, contributing to the oversight.
Arbitration Agreement Language Deficiency
Penalty
Summary
The facility failed to include specific language in its arbitration agreement for two residents, which is a requirement to ensure that residents and their families are informed of their rights. The arbitration agreement did not explicitly state that signing the agreement was not a condition for admission or continued care at the facility. This omission was identified during a review of the facility's documents and interviews with staff. The Business Office Manager confirmed that the current admission agreement lacked the necessary language, indicating a lack of awareness of this requirement. Two residents, who were cognitively intact as indicated by their BIMS scores, signed the arbitration agreements without being informed that it was not mandatory for their admission or continued care. The residents' electronic medical records and the facility's arbitration agreements were reviewed, revealing the absence of the required language. The Business Office Manager, responsible for completing the admission packets, acknowledged the deficiency during an interview, confirming that the agreements did not contain the necessary information.
Failure to Provide SNFABN Notices to Residents
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to two residents, R145 and R146, which is necessary for informing them or their representatives about potential financial liabilities for services not covered by Medicare. The deficiency was identified through interviews, record reviews, and facility policy reviews. The facility's failure to issue the SNFABN prevented the residents or their representatives from making informed decisions regarding the costs of continued therapy services after the end of their skilled services. For resident R145, the facility's records indicated that skilled services ended on 08/21/24, yet the resident remained in the facility without receiving the SNFABN. Similarly, for resident R146, skilled services ended on 08/08/24, and the resident also stayed in the facility without receiving the necessary notice. During an interview, the Administrator acknowledged that the previous social services staff member was responsible for distributing the ABN notices, but confirmed that only the Notice of Medicare Non-Coverage was provided to the residents' representatives, not the SNFABN.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide written notification regarding the reason for hospital transfers for three residents, which is a requirement under federal regulations. The facility did not have a policy in place to ensure that written notices were given to residents or their representatives when a transfer to the hospital occurred. This deficiency was confirmed through interviews with the Administrator and the Director of Nursing, who acknowledged the absence of such a policy and the lack of enforcement of the requirement. The deficiency involved three residents who were transferred to the hospital without written notification being provided to them or their responsible parties. One resident, who was severely cognitively impaired, was transferred twice due to medical issues without written notice to his representative. Another resident, experiencing altered mental status and other symptoms, was sent to the emergency room without written notification to the resident or their responsible party. Similarly, a third resident was transferred to the hospital due to a medical condition without written notice being provided. The Administrator confirmed the lack of documentation for these notifications during an interview.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of its Bed Hold Policy to residents or their representatives prior to hospital transfers, as required by its own policy. This deficiency was identified through a review of records for three residents who were hospitalized. Resident 64, who was severely cognitively impaired, was transferred to the hospital twice for medical issues, but there was no documentation indicating that his spouse, who was his representative, received the bed hold policy in writing. Similarly, Resident 70 was transferred to the hospital on two occasions due to altered mental status and lethargy, yet there was no evidence that the bed hold policy was communicated to the responsible party in writing. Additionally, Resident 94 was sent to the emergency room due to a significant drop in pulse and oxygen levels, as well as a concerning physical finding, but again, there was no documentation of the bed hold policy being provided in writing. The facility's administrator confirmed the absence of such documentation in the residents' records and acknowledged that the facility's policy was not followed. This oversight created the potential for residents and their representatives to be uninformed about their rights regarding bed hold procedures during hospital transfers.
Failure to Submit PASARR Level II for Resident with New Mental Health Diagnosis
Penalty
Summary
The facility failed to make a referral for a Level II Preadmission Screening and Resident Review (PASARR) evaluation for a resident who was diagnosed with major depressive disorder. The facility's policy, as outlined in a document titled 'Resident Assessment-Coordination with PASARR Program' dated 02/12/22, requires that any resident exhibiting a newly evident or possible serious mental disorder be promptly referred to the state mental health authority for a Level II resident review. Despite this policy, the facility did not submit a PASARR Level II evaluation for the resident after a psychiatric provider diagnosed them with major depressive disorder on 01/04/24. The resident, identified as R31, was admitted to the facility without a diagnosis of major depressive disorder, as indicated in a PASARR Level I document dated 05/05/23. However, a psychiatric diagnostic evaluation later identified the resident with major depressive disorder, and the resident's care plan dated 05/13/24 noted the use of antidepressant medication for this condition. Despite these developments, the facility's records did not show evidence of a PASARR Level II submission following the new diagnosis. During an interview, the Administrator confirmed that the expectation was for social services to submit a new PASARR when a new mental health diagnosis is identified.
Failure to Label Enteral Feeding Bag
Penalty
Summary
The facility failed to label an enteral feeding bag according to professional standards for a resident with a history of dysphagia following cerebral infarction and gastroparesis. The resident was receiving enteral nutrition via a PEG tube, as per physician orders, which specified the feeding schedule and rate. However, during an observation, it was noted that the feeding bag lacked essential labeling information such as the date, time started, resident's name, and initials. This omission was confirmed by the LPN on duty, who stated that the night shift nurse was responsible for hanging the bag and should have completed the label. Interviews with the nursing staff revealed a lack of clarity and accountability regarding the labeling process. The LPN who worked the night shift admitted to not checking the label, although she was assigned to the resident. The Director of Nursing confirmed that it was standard practice to complete the labels for safety reasons, as enteral feeding is only viable for 24 hours. The facility's policy and competency documents also emphasized the importance of proper labeling to ensure compliance with clinical standards and prevent complications.
Limited Access to Resident Funds Due to Restricted Banking Hours
Penalty
Summary
The facility failed to ensure the timely availability of personal resident funds for three residents, as the banking hours were limited to Monday through Friday from 9:00 AM to 3:00 PM, with no access on weekends. This deficiency was identified through record reviews and interviews with residents and staff. Resident 3, who was moderately cognitively impaired, expressed a desire to access her funds on weekends, which was previously possible but had since been restricted. Resident 31, who was cognitively intact, also wished to access his funds daily, including weekends, but was unable to do so due to the limited banking hours. Resident 37, who was mildly cognitively impaired, wanted to access her funds on Sundays to give money to her son for purchases, but was similarly restricted by the facility's banking schedule. Interviews with the Medical Record Director and the Business Office Manager confirmed that residents could not access their personal needs accounts outside the posted banking hours. The Medical Record Director, responsible for the personal needs accounts, acknowledged the lack of access during evenings and weekends. The Business Office Manager and the Administrator confirmed this limitation, with the Administrator stating her expectation that residents should have reasonable access to their personal funds. Despite this expectation, the facility's current banking hours did not accommodate residents' needs for accessing their funds outside of the specified times.
Failure to Provide Quarterly Financial Statements to Residents
Penalty
Summary
The facility failed to ensure accurate financial accounting and record retention for two residents, R31 and R37, regarding their Personal Needs Accounts. R31, who was cognitively intact with a BIMS score of 15, confirmed that the facility managed his money but did not provide him with a quarterly statement of his account. Similarly, R37, who was mildly cognitively impaired with a BIMS score of 12, also confirmed that she did not remember receiving quarterly statements for her account. The Medical Records Director acknowledged that the facility was managing funds for both residents and confirmed that neither received their quarterly statements. Instead, the statements were sent to the Resident Representative listed in each resident's record, following the director's process of sending statements to representatives regardless of the resident's cognitive ability. The Administrator stated that her expectation was for cognitively intact residents capable of understanding their finances to receive their quarterly statements.
Failure to Release Resident Funds Timely
Penalty
Summary
The facility failed to release resident funds managed in Personal Needs (PN) Accounts to the residents or their Responsible Parties (RP) within 30 days of discharge, as required by federal regulations. This deficiency was identified for three residents, each of whom had passed away in the facility. Resident R195, who had Alzheimer's Disease and respiratory failure, passed away over 13 months prior to the survey, yet still had an active PN Account with a balance of $4882.92. Similarly, Resident R197, with type 2 diabetes, passed away over four months prior, with a remaining balance of $233.00 in their PN Account. Resident R199, diagnosed with liver and colon cancers, passed away nearly seven months before the survey, leaving a balance of $170.00 in their account. Interviews with facility staff, including the Medical Records Director and the Administrator, confirmed the existence of these balances and the failure to return the funds to the respective RPs. The Medical Records Director was unable to provide an explanation for the delay in returning the funds. The Administrator acknowledged the deficiency, stating that the facility's expectation was to return funds within 30 days of discharge, in accordance with federal regulations. This oversight indicates a lapse in the facility's management of resident funds, affecting the timely conveyance of funds to the appropriate parties.
Medication Administration Errors in Insulin Delivery
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 6.06% error rate during the survey. This deficiency was identified through the review of medication administration for two residents, both diagnosed with Type 2 Diabetes, who were receiving insulin via pen injectors. The first resident, R54, was administered insulin by an LPN who did not leave the insulin pen needle inserted in the resident's skin for the required six to ten seconds, potentially affecting the full absorption of the medication. The LPN admitted to being unaware of this requirement, which was outlined in the facility's insulin policy. The second resident, R79, was administered insulin by another LPN who failed to prime the insulin pen needle before administration, which is necessary to ensure no air is injected instead of insulin. The LPN stated she had not been instructed to prime the needle unless air was visible in the pen chamber. The Director of Nursing confirmed that the facility's policy required priming the insulin pen with two units before each administration and leaving the needle in the skin for the specified duration to ensure proper medication delivery.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection control program for two residents, leading to potential health risks. One resident, who was COVID-19 positive, was not properly isolated as staff failed to don personal protective equipment (PPE) before entering the resident's room. Despite clear signage indicating droplet precautions and the presence of a PPE cart outside the room, a Certified Nurse Aide (CNA) entered without wearing the necessary protective gear. The interim Infection Preventionist and the Director of Nursing acknowledged the oversight and confirmed that no recent in-services had been provided to staff regarding isolation precautions. Another deficiency was observed with a resident who had an indwelling catheter. The catheter tubing was repeatedly observed in contact with the floor, which poses a risk of infection. The resident, who had diagnoses including Down Syndrome and urinary retention, was unable to communicate effectively due to cognitive impairments. Despite multiple observations throughout the day, the catheter tubing remained on the floor, and a CNA confirmed that it should not be in contact with the floor to prevent infection. The facility's policies on transmission-based precautions and catheter care were not adhered to, as evidenced by the staff's actions and the condition of the residents' care. The Director of Nursing and the Administrator both stated their expectations for staff to follow infection control policies, yet the observed practices did not align with these expectations, leading to the identified deficiencies.
Failure to Administer Pneumococcal Vaccines Timely
Penalty
Summary
The facility failed to offer the pneumococcal vaccination in accordance with CDC guidelines for two residents, R48 and R55, who were over the age of 65. R48 was admitted to the facility and had signed a consent form to receive a pneumococcal vaccine. The resident was administered the PCV15 vaccine, but the follow-up PPSV23 vaccine was not offered or administered within the recommended timeframe of one year. This oversight occurred because the registered nurse (RN2) did not transfer the due date for the next vaccination from the consent form to her tracking log, leading to the omission. Similarly, R55 was administered the PPSV23 vaccine but was not offered the subsequent PCV15 or PCV20 vaccine within the recommended timeframe. The same RN2 was responsible for this oversight, as she failed to transfer the due date to her tracking log. The interim Infection Preventionist and the Director of Nursing were unaware of these lapses, and the Administrator expected the staff to obtain consent and administer vaccines timely. These failures had the potential to increase the risk for the residents to contract pneumonia.
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 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.
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.
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.
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.
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 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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