Cambridge Post Acute Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Snellville, Georgia.
- Location
- 2020 Mcgee Road, Snellville, Georgia 30078
- CMS Provider Number
- 115771
- Inspections on file
- 19
- Latest survey
- February 6, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Cambridge Post Acute Care Center during CMS and state inspections, most recent first.
A resident with Alzheimer's disease and severe cognitive impairment, who was care planned to have her dignity and autonomy maintained, was self-propelling in a wheelchair and expressing the need to use the bathroom when a CNA stopped her and attempted to redirect her away from the hall she chose. When the resident insisted on going in her chosen direction and became upset, the CNA backed her wheelchair against a wall across from the nurses' station and locked the wheels to prevent further movement. The DON acknowledged that restricting a resident’s movement is against residents’ rights, and the Administrator stated that residents have the right to wander in the building, while also noting that residents are kept lined up near the nurses’ station for supervision, despite a facility policy requiring residents be treated with dignity and respect and that their input be honored.
A resident with a PICC line did not receive care according to facility policy and physician orders, including missed and improperly performed dressing changes, lack of chest x-ray confirmation after line insertion, and use of the line without placement verification. Staff interviews and observations revealed inconsistent practices, breaks in sterile technique, and incomplete adherence to enhanced barrier precautions.
A resident receiving IV antibiotics via a PICC line for infection and sepsis experienced multiple missed doses of prescribed medications when the PICC line was not usable. Nursing staff did not notify the physician or obtain alternative orders as required by facility policy, resulting in significant medication errors.
Staff did not consistently follow Enhanced Barrier Precautions and hand hygiene protocols during wound care for two residents with significant wounds and cognitive impairment. An LPN failed to use barriers for supplies, did not sanitize shared wound care items, and neglected to wear gowns or change gloves appropriately during high-contact care, despite posted precautions and facility policy. Staff interviews confirmed knowledge of protocols but acknowledged lapses in practice.
The facility failed to ensure proper labeling and storage of residents' basins, urinals, and bedpans in 11 shared rooms, as per their policy. Observations revealed these items were often unlabeled, unbagged, or placed on the floor, posing a risk of cross-contamination. The ICP confirmed that CNAs were responsible for proper labeling and storage, but this was not consistently done.
Three residents were found with unauthorized and unsecured medications at their bedside, posing a risk of medication errors and unauthorized access. One resident with moderate cognitive impairment had over-the-counter medication provided by her son, another had a pill he was unsure about, and a third had eye drops brought by family. None had been assessed or approved for self-administration, contrary to facility policy.
The facility failed to create comprehensive care plans for two residents, one with MRSA and another dependent on oxygen therapy. Despite documented diagnoses and physician orders, the care plans did not address these critical needs. Interviews with staff confirmed these oversights.
The facility failed to administer oxygen therapy according to physician orders and maintain clean oxygen concentrator filters for several residents. A resident received oxygen at a higher rate than prescribed, and observations revealed dirty filters on concentrators for three residents. The DON and LPNs confirmed the discrepancies and the responsibility of Sunday night shift nurses for equipment maintenance.
A facility failed to maintain a medication error rate below five percent, resulting in a 7.69 percent error rate for a resident with type 2 diabetes and IBS. An LPN administered an incorrect dosage of Linzess and failed to prime an insulin pen before use. The DON emphasized the importance of following medication administration protocols.
The facility failed to provide written information about its bed-hold policy to residents or their representatives during hospital transfers. This deficiency was identified for three residents, who did not receive the required documentation, leading to confusion and distress among families. Interviews with staff confirmed the lack of communication regarding the bed-hold policy.
The facility failed to implement its Antibiotic Stewardship program effectively, as two residents were prescribed antibiotics without using the McGreer Criteria to assess clinical indications. The Infection Control Preventionist admitted to not conducting infection surveillance due to a lack of training, resulting in inadequate monitoring and documentation of antibiotic use.
The facility's Infection Control Preventionist (ICP) failed to adequately manage the Infection Control and Prevention (IPCP) program, as required by the facility's policy. Despite completing the CDC Nursing Home Infection Preventionist Training Course, the ICP did not update her training since November 2022 and failed to implement necessary infection control measures, including an antibiotic stewardship program. This deficiency placed the facility's 136 residents at risk for infection transmission. The Administrator was aware of some issues but not the full extent.
The facility failed to maintain a safe and sanitary environment, with peeling wallpaper and water-stained ceiling tiles in a resident's room, and an unclean porch area with cat hair and urine odor. Residents expressed discomfort due to these conditions, and the Environmental Director acknowledged the need for regular cleaning.
The facility failed to develop person-centered care plans for residents with communication needs. A resident with a cochlear implant and moderate hearing difficulty lacked a care plan for hearing loss. Another resident with severe cognitive impairment and a preferred language of Korean had no care plan for her language barrier. A resident with moderate cognitive impairment and a preferred language of Spanish also lacked a care plan for his language barrier, and there were no communication boards available. A resident who preferred Vietnamese and had no cognitive impairment was unable to consistently communicate in English and did not have a care plan addressing this issue.
The facility failed to ensure that Certified Medication Technicians (CMTs) were competent in insulin administration, as three out of five CMTs lacked documented skills and knowledge. CMT MM had no completed competency checklist, CMT LL was unaware of the need for insulin dosage verification by a licensed nurse, and CMT FF was uncertain about her competencies. The Staff Development Coordinator confirmed the absence of specific competency documentation for insulin administration.
The facility failed to administer medications as ordered for two residents, leading to missed doses of critical medications. One resident missed doses of an inhaler and Atorvastatin, while another missed doses of Pregabalin. Interviews revealed systemic issues, including challenges with insurance authorizations and delays in medication delivery, contributing to these failures.
A LTC facility failed to administer insulin as ordered for three residents, leading to significant medication errors. Discrepancies were found in blood sugar documentation and insulin administration, with multiple instances of insulin not being given according to sliding scale orders. Interviews revealed a lack of awareness and oversight by the facility's staff.
The facility failed to implement enhanced barrier precautions (EBP) and transmission-based precautions (TBP) for two residents, leading to potential cross-contamination. A resident with pressure sores did not receive proper PPE use during wound care, and signage was not visible. Another resident with a PICC line and MRSA had delayed TBP implementation, with staff unaware of the need for precautions. The Infection Control Preventionist was absent, and the Unit Manager did not ensure proper signage and PPE availability.
A facility failed to update a resident's care plan to include interventions for an unstageable sacral pressure ulcer. The resident, with a history of cerebral vascular accident and other conditions, had a care plan that addressed other wounds but not the sacral ulcer. The MDS Coordinator confirmed the oversight, which placed the resident at risk for unmet care needs.
Expired insulin vials were found on two medication carts, posing a risk to residents. An LPN confirmed that a Lantus insulin vial was used past its expiration, and another vial of Novolog lacked an open date. The pharmacist and DON acknowledged ongoing issues with expired medications, emphasizing the need for immediate removal from carts.
A resident with Alzheimer's disease and dementia did not receive or refuse the pneumonia vaccine, and there was no documentation of education or administration in their medical record. The facility's policy requires documentation of immunization status upon admission, but staff interviews revealed confusion over responsibility, with the Unit Manager unaware of the resident's vaccination status. The administrator was aware of issues but not the full extent.
A resident was not provided education or offered the COVID-19 vaccine, as required by the facility's policy. The resident's medical record lacked documentation of the vaccine being offered, administered, or declined, despite the resident having no cognitive impairment. Interviews with staff revealed confusion over responsibility for vaccine documentation, and the DON confirmed the resident had not received the vaccine or signed a declination.
Resident’s Right to Dignity and Freedom of Movement Not Respected
Penalty
Summary
A resident with Alzheimer's disease and a severe cognitive impairment, evidenced by a BIMS score of five on a recent quarterly MDS assessment, was observed self-propelling in a wheelchair near the nurses' station while verbalizing the need to use the bathroom. As the resident moved toward A Hall, a CNA approached from behind, stopped the wheelchair, and attempted to redirect the resident in another direction. The resident pointed down the hall and stated she wanted to go that way, but the CNA told her she did not need to go down there. The resident's tone elevated, and she began hitting the arm of her wheelchair while repeatedly stating she wanted to go toward A Hall. The CNA then grabbed the wheelchair handles, backed the resident up against the wall across from the nurses' station, and locked the wheelchair wheels to prevent her from moving down the hall or entering other residents' rooms. The resident's care plan, dated 10/27/2025, included goals to maintain her dignity and autonomy at the highest level, with interventions such as respecting her wishes and working with nursing staff to provide maximum comfort. The DON confirmed that restricting a resident's movement throughout the facility is against residents' rights and choices, and the Administrator stated that residents have the right to wander anywhere in the building, noting that residents are kept lined up in front of the nurses' station for more supervision. The facility's Resident Rights policy stated that each resident has the right to be treated with dignity and respect and that staff must honor and value each resident's input.
Failure to Follow PICC Line Care Protocols and Placement Verification
Penalty
Summary
A deficiency occurred when the facility failed to follow its own policy and physician's orders regarding the care and management of a resident's Peripherally Inserted Central Catheter (PICC) line. The facility's policy required weekly dressing changes for transparent dressings and dressing changes every 48 hours for gauze dressings, or as ordered by the physician. However, the resident reported that the PICC line dressing had not been changed since insertion, and observations confirmed that the dressing was not dated or timed, and included gauze under a transparent dressing. Staff interviews revealed inconsistent practices regarding dressing changes and a lack of adherence to established protocols. Additionally, after the PICC line was reinserted, a chest x-ray to confirm placement was not ordered or performed, despite this being a standard requirement and expectation communicated by the PICC line insertion company. The resident's medical record did not contain documentation of a chest x-ray following the new PICC line insertion, and the line was used for intravenous therapy without confirmation of proper placement. Interviews with staff, including the DON and ADON, confirmed that the chest x-ray was not completed and that the line had been used daily since insertion. During an observed dressing change, further deviations from protocol were noted, including a break in sterile technique, failure to change the stabilization device and antibacterial disk, and incomplete use of enhanced barrier precautions. The resident had a history of infection, recent surgical procedures, and required IV antibiotics via the PICC line. The facility's failure to follow established protocols and physician orders for PICC line care, dressing changes, and placement verification led to the identified deficiency.
Failure to Prevent Significant Medication Errors Due to Missed IV Antibiotic Doses
Penalty
Summary
A resident with a history of intraspinal abscess, infection following a procedure, candidiasis, COPD, asthma, depression, and muscle weakness was admitted and receiving IV antibiotic therapy via a PICC line for sepsis and infection. The resident's care plan included administration of IV antibiotics and fluids as ordered, with specific interventions for PICC line maintenance and monitoring for adverse reactions. Physician orders included Micafungin Sodium-NaCl IV solution to be given every 24 hours and Cefazolin Sodium injection every eight hours for a specified duration. Review of the Medication Administration Record (MAR) revealed multiple missed doses of both Cefazolin and Micafungin on several dates. The missed doses were marked as not given, and interviews with nursing staff indicated that when the PICC line was not usable or had come out, the antibiotics were not administered until the line was reinserted. The facility's policy required nurses to notify the physician if medication would be given late or to obtain an alternative order, but this protocol was not followed. The DON confirmed that the expectation was for nurses to contact the physician for an alternative route or order when the PICC line was not available.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Wound Care
Penalty
Summary
Staff failed to consistently follow infection control practices related to Enhanced Barrier Precautions (EBP) and hand hygiene during wound care for two residents receiving wound treatment. For one resident with a stage 4 pressure ulcer and significant cognitive impairment, a nurse performed a dressing change while following some EBP protocols, such as donning a gown and performing hand hygiene. However, the nurse did not use a barrier for wound care supplies, placed a multi-resident wound cleanser bottle directly on the bedside drawer, and returned the bottle to the treatment cart without sanitizing it. For another resident with multiple wounds, severe cognitive impairment, and a Foley catheter, staff did not wear gowns during high-contact wound care activities despite EBP signage on the door. The LPN removed soiled dressings and applied new ones without changing gloves or performing hand hygiene between steps. The LPN also used a personal marker while wearing contaminated gloves and returned it to her pocket without cleaning it. During the dressing change on a different wound, gloves were changed but hand hygiene was not performed after glove removal. Interviews with staff confirmed awareness of EBP protocols and the need for gowns and hand hygiene during high-contact care, but acknowledged lapses in practice. The Infection Preventionist and Director of Nursing both stated that staff were educated on these protocols and that expectations included consistent adherence to infection control practices, including hand hygiene and use of PPE for residents with wounds or indwelling devices.
Failure to Label and Store Personal Care Items Properly
Penalty
Summary
The facility failed to ensure proper labeling and storage of residents' personal care items, such as basins, urinals, and bedpans, in 11 out of 69 shared rooms. According to the facility's policy titled 'Giving a Bed bath,' these items should be labeled with the resident's name, placed in a clean plastic bag, and stored appropriately. However, observations revealed that many of these items were either unlabeled, unbagged, or placed directly on the floor, which contradicts the facility's policy and poses a risk of cross-contamination. During an inspection, the Infection Control Preventionist (ICP) confirmed the presence of numerous unlabeled and unbagged items in various shared bathrooms across different halls. The ICP acknowledged that Certified Nursing Assistants (CNAs) were responsible for ensuring that all personal care items were properly labeled and stored, but this was not consistently done. The failure to adhere to the established procedures for labeling and storing these items could potentially expose residents to infections due to cross-contamination.
Unauthorized and Unsecured Medications at Bedside
Penalty
Summary
The facility failed to ensure that three residents did not have unauthorized and unsecured medications at their bedside, which could lead to medication errors and unauthorized access by other residents. Resident R45, who had a moderate cognitive impairment, was found with over-the-counter medication on her bedside table. She was unaware that she was not allowed to have medications at the bedside, and her son had provided the medication. The facility's policy requires an interdisciplinary team to assess and approve self-administration of medication, but R45's records lacked such approval or a care plan for self-administration. Resident R113, also with moderate cognitive impairment, was found with a pill on his bedside table. He was unsure of its purpose and had not been assessed for self-administration of medications. A Licensed Practical Nurse confirmed that R113 was not capable of self-medication and that staff were required to supervise his medication intake. The Director of Nursing stated that the facility does not generally allow self-administration of medication without an assessment and permission. Resident R432, with intact cognition, was found with eye drop medication on her bedside table. She had not been assessed for self-administration, and her family had brought the medication from the hospital without the facility's knowledge. The facility's policy requires medications to be stored securely if self-administration is approved, but R432's records lacked a care plan or approval for self-administration.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for two residents, leading to deficiencies in addressing their specific medical needs. One resident, diagnosed with Methicillin-resistant Staphylococcus aureus (MRSA), was readmitted to the facility without a care plan addressing this infection. Despite the resident's condition being documented in various assessments and progress notes, the care plan did not reflect the necessary interventions for managing MRSA. Interviews with the LPN/MDS Coordinator and the Director of Nursing confirmed that the oversight occurred, and the care plan should have included measures for the infection. Another resident, who was dependent on supplemental oxygen due to conditions such as asthma and a malignant neoplasm, also lacked a care plan for oxygen therapy. The resident's medical records indicated a physician's order for continuous oxygen therapy, yet this was not incorporated into the care plan. Interviews with the LPN/MDS Coordinator and the Director of Nursing revealed that the absence of an oxygen therapy plan was an oversight, as the care plan should have reflected the resident's dependency on continuous oxygen.
Oxygen Therapy and Equipment Maintenance Deficiencies
Penalty
Summary
The facility failed to administer oxygen therapy in accordance with physician orders and maintain clean oxygen concentrator filters for several residents. One resident, who was admitted with asthma and dependence on supplemental oxygen, was observed receiving oxygen at a rate of 3 liters per minute, contrary to the physician's order of 2 liters per minute. This discrepancy was confirmed by the Director of Nursing and a Licensed Practical Nurse, who verified the physician's order in the facility's electronic records. Additionally, the facility did not ensure the cleanliness of oxygen concentrator filters for three residents. Observations revealed that the filters contained thick gray or dark brown substances, indicating they had not been cleaned as required. Interviews with the Director of Nursing and Licensed Practical Nurses confirmed that the responsibility for cleaning these filters fell on the Sunday night shift nurses, with rounds conducted on Monday mornings to ensure compliance. However, the observations indicated that the maintenance and cleaning of the oxygen equipment were not properly executed.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 7.69 percent for one resident. This deficiency was identified through observations, staff interviews, and record reviews. The facility's policy on administering medications requires that medications be administered safely, timely, and as prescribed, with the individual administering the medication verifying the right resident, medication, dosage, time, and method of administration. However, during a medication pass observation, an LPN administered an incorrect dosage of Linzess to a resident, giving two capsules of 290 mg each instead of the prescribed 145 mg capsules. Additionally, the LPN failed to prime the insulin pen needle before administering insulin, which could lead to the resident receiving a decreased dose. The resident involved had diagnoses including type 2 diabetes and irritable bowel syndrome. The LPN confirmed the error in dosage and acknowledged not priming the insulin pen, stating a lack of awareness of the need to prime the pen. The Director of Nursing emphasized the importance of following the five rights of medication administration and adhering to physician orders and manufacturer's guidelines. The DON noted that incorrect medication dosages could potentially cause adverse effects and that the insulin pen should be primed to ensure the correct dose is administered.
Failure to Provide Bed-Hold Policy Information
Penalty
Summary
The facility failed to provide written information about its bed-hold policy to residents or their representatives when transferring residents to the hospital. This deficiency was identified for three residents who were reviewed for bed hold. The facility's Bed-Hold Policy, revised in January 2011, requires that residents or their representatives be informed about the policy concerning reserving beds during hospital stays. However, the facility did not adhere to this policy, as evidenced by the lack of written communication provided to the residents or their families at the time of transfer. For instance, one resident was transferred to the hospital due to an ear infection and did not return to the facility. The family was informed by phone to remove the resident's belongings, as the bed was no longer available, without prior written notice about the bed-hold policy. Another resident, transferred due to edema and pain, did not recall receiving any written information about the bed-hold policy. A third resident, transferred due to respiratory distress, also did not receive any documentation regarding the bed-hold policy. Interviews with facility staff, including the MDS Coordinator and the DON, confirmed that the facility did not provide or send any information about the bed-hold policy to residents or their families during hospital transfers.
Failure in Antibiotic Stewardship Program Implementation
Penalty
Summary
The facility failed to properly implement its Antibiotic Stewardship program, as evidenced by the lack of assessment and determination of clinical indications for antibiotic use using the McGreer Criteria for two residents. Resident 16 was admitted with conditions including diabetes and cellulitis and was identified to have a positive urine culture for Escherichia coli and ESBL. Despite being started on antibiotics, there was no evidence of the McGreer criteria being used to justify the antibiotic treatment. Similarly, Resident 17, admitted with diastolic congestive heart failure and asthma, was also started on antibiotics following a positive urine culture for Escherichia coli and Proteus mirabilis, without documentation of the McGreer criteria being applied. The facility's policy on Antibiotic Stewardship, dated April 2022, outlines the need for a multidisciplinary program to monitor and guide antibiotic use, including the use of established guidelines for infection identification and treatment. However, the Infection Control Preventionist (ICP) admitted to not conducting infection surveillance due to a lack of training, and there was no documentation of signs and symptoms or the McGreer criteria worksheet for the residents involved. This lack of systematic protocols and documentation led to the deficiency in monitoring and assessing antibiotic use effectively.
Inadequate Management of Infection Control Program
Penalty
Summary
The facility failed to ensure that the designated Infection Control Preventionist (ICP) adequately assessed, developed, implemented, monitored, and managed the Infection Control and Prevention (IPCP) program. This deficiency was identified through a review of records, interviews, and the facility's policy titled Infection Control - Infection Preventionist. The policy mandates that a qualified professional be employed to establish and maintain an infection control and prevention program. However, the ICP did not fulfill these responsibilities, which included implementing a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases. The ICP also failed to ensure the implementation of an antibiotic stewardship program and did not update her infection control training since November 2022. The facility's census was 136 at the time of the survey, and the lack of adequate infection control measures created the potential for an ineffective program, placing residents at risk for the transmission of infections and communicable diseases. The ICP had completed the CDC Nursing Home Infection Preventionist Training Course in November 2022, but no further training or education was obtained since then. The facility's Administrator acknowledged awareness of some issues but was not fully aware of the extent of the deficiencies. The report cross-references deficiencies F880, F881, F883, and F887.
Environmental Deficiencies in Facility Maintenance
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and visitors, as evidenced by several observations and interviews. In room C14, the wallpaper was peeling away from the wall, and there were large brown water stains on the ceiling tiles, indicating a lack of maintenance and repair. Additionally, the exterior of the facility was not aesthetically appealing, with garbage and debris such as tissues, paper, disposable cups, and a face mask scattered in the parking lot, on the sidewalk, and inside the covered porch at the front entrance, despite the presence of a trash bin nearby. The porch area at the entrance of the facility was also found to be unclean and unsafe due to the presence of cat hair on the outdoor furniture cushions and a strong odor of cat urine. Residents expressed their discomfort and reluctance to use the porch area due to the presence of cats, which were seen jumping out from behind bushes near the entrance. The Activity Assistant acknowledged the issue, noting that one resident feeds the cats, which contributes to the problem. The Environmental Director confirmed the unsightly condition of the area and acknowledged the need for regular cleaning, especially during peak visitor times.
Failure to Address Communication Needs in Care Plans
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans addressing communication needs for four residents. Resident 4, who had a cochlear implant and moderate hearing difficulty, did not have a care plan focusing on hearing loss. Resident 18, with severe cognitive impairment and a preferred language of Korean, lacked a care plan addressing her inability to speak English. Staff communicated with her using hand gestures. Resident 26, with moderate cognitive impairment and a preferred language of Spanish, also lacked a care plan for his language barrier. He communicated with staff using gestures, and there were no communication boards available. Resident 27, who preferred Vietnamese and had no cognitive impairment, was unable to consistently communicate in English and did not have a care plan addressing this issue. The MDS Coordinator confirmed that the care plans were not person-centered to reflect the residents' communication needs.
Deficiency in CMT Competency for Insulin Administration
Penalty
Summary
The facility failed to ensure that Certified Medication Technicians (CMTs) met professional standards of quality in administering insulin to residents. Specifically, three out of five CMTs (CMT MM, CMT LL, and CMT FF) were found to lack documented competencies in insulin administration. CMT MM, hired on March 8, 2024, admitted to not having completed skills competencies at the current facility, although she had done so at her previous job. There was no Medication Administration - Subcutaneous Injection checklist completed for CMT MM. CMT LL, hired on August 22, 2022, was unaware of the requirement to have insulin dosages verified by a licensed nurse, as per the Georgia State Certification Medication Aide policy. Her Medication Administration - Subcutaneous Injection checklist was unsigned. CMT FF, hired on November 11, 2020, was uncertain about her yearly competencies related to insulin administration, and her checklist was also unsigned. The Staff Development Coordinator confirmed the lack of competency documentation specific to insulin administration for the CMTs, indicating a systemic issue in ensuring proper training and verification processes.
Medication Administration Failures
Penalty
Summary
The facility failed to ensure medications were administered as ordered for two residents, R17 and R25, leading to missed doses of critical medications. R17, who was cognitively intact and had diagnoses including COPD and asthma, missed 20 doses of her Xopenex inhaler and 13 doses of Atorvastatin over two months. During a resident council meeting, R17 expressed concerns about running out of medications and the facility's lack of care in ensuring medication availability. Similarly, R25, who had moderate cognitive impairment and suffered from diabetes and neuralgia, missed seven doses of Pregabalin. R25 also reported delays in receiving medications, taking two to three days for reorders. Interviews with facility staff revealed systemic issues contributing to the medication administration failures. The Nurse Practitioner acknowledged the problem of medications not being administered on time. The Director of Nursing cited challenges with insurance companies requiring repeated prior authorizations, which contributed to medication delays. The Pharmacy Consultant indicated that nurses should be able to obtain medications through the pharmacy's website or by calling, but was unaware of any issues related to prior authorizations. The facility's policies on pharmacy services and medication delivery expectations were not effectively implemented, resulting in the deficiencies observed.
Insulin Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure proper administration of insulin as ordered for three residents, leading to significant medication errors. For Resident 15, there were multiple instances where insulin was not administered according to the sliding scale orders, despite blood sugar levels indicating the need for insulin. Specifically, there were 16 occasions where insulin was not given when blood sugar levels were between 0-160, and additional instances where blood sugar levels exceeded 160 but insulin was not administered. This included a blood sugar reading of 363 on one occasion and 347 on another, both without corresponding insulin administration. Resident 11 also experienced discrepancies in insulin administration. The November 2023 MAR showed inconsistencies between recorded blood sugar levels and the sliding scale documentation, with insulin not administered when required. There were 28 instances where 'NA' was used incorrectly, and specific dates where insulin was not given despite high blood sugar readings. Similar issues persisted into December 2023, with discrepancies between blood sugar documentation and insulin administration, including instances where insulin was administered based on incorrect blood sugar readings. For Resident 5, the January 2023 MAR revealed that insulin was not administered according to sliding scale orders on multiple occasions, including a blood sugar reading of 253 and another of 397. In February 2023, there were further instances of missing documentation for blood sugar checks and insulin administration. Notably, a blood sugar reading of 40 was recorded without documentation of physician notification or resident condition. Interviews with the Nurse Practitioner and Director of Nursing highlighted a lack of awareness and oversight regarding these insulin administration issues.
Failure to Implement Enhanced Barrier and Transmission-Based Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) and transmission-based precautions (TBP) for two residents, R19 and R20, which could lead to cross-contamination and infection spread. For R19, who was readmitted with conditions including a cerebral vascular accident and multiple pressure sores, the facility did not ensure that personal protective equipment (PPE) was used during wound care. An LPN was observed providing wound care without wearing a gown, and the EBP signage was not visible, being placed on the floor behind the door. The LPN was unaware of the need for EBP for R19, indicating a lack of communication and training. For R20, who was admitted with pneumonia, open wounds, and a PICC line, the facility delayed implementing TBP. A CNA placed PPE and TBP signage on the door seven days after admission, and the Unit Manager admitted to not being aware of R20's MRSA status until reviewing discharge paperwork. The Infection Control Preventionist (ICP) was not present the previous week, and the signage was not appropriately placed, leading to confusion among staff. The Unit Manager was responsible for ensuring visibility of EBP and TBP signage and accessibility of PPE, but this was not adequately managed.
Failure to Update Care Plan for Sacral Pressure Ulcer
Penalty
Summary
The facility failed to revise a resident's person-centered comprehensive care plan to include interventions for a sacral pressure ulcer. The care plan, which should be updated when there is a significant change in the resident's condition, did not reflect the presence of an unstageable sacral pressure ulcer for a resident who was readmitted with diagnoses including cerebral vascular accident with right-sided paralysis, seizures, and vascular dementia. The care plan was last revised to address new wounds on the resident's legs and heel but did not include the sacral pressure ulcer. The MDS Coordinator confirmed during an interview that the care plan for the resident's skin impairment had not been updated to include the unstageable sacral wound, despite the facility's policy requiring such updates. This oversight placed the resident at risk for unmet care needs, as the care plan did not incorporate necessary interventions for the sacral pressure ulcer, which was identified in a wound evaluation and management summary.
Expired Insulin Vials Found on Medication Carts
Penalty
Summary
The facility failed to ensure that expired insulin vials were removed from two of five medication carts, which placed residents at risk of receiving ineffective medications. During an inspection of the B-Hall medication cart, an LPN confirmed that a vial of Lantus insulin, opened on 6/1/2024, had been used beyond its 28-day expiration period. Additionally, an inspection of the C-Hall medication cart revealed a vial of Novolog insulin without an open or use-by date, and the LPN confirmed that this insulin had been administered to a resident without knowledge of its expiration. Interviews with the facility's pharmacist and the Director of Nursing (DON) highlighted ongoing issues with expired medications. The pharmacist, who conducts monthly cart monitoring, acknowledged the persistent problem of expired insulins at the facility and noted that nurses are responsible for checking medication carts for expired medications. The DON confirmed that expired medications should not be available for use and should be removed immediately from medication carts.
Failure to Document and Administer Pneumonia Vaccine
Penalty
Summary
The facility failed to provide education, offer, or administer the pneumonia vaccination to a resident diagnosed with Alzheimer's disease and dementia. Upon review of the resident's clinical record, it was found that there was no documentation of the pneumonia vaccine being administered or refused since the resident's admission. The facility's policy mandates that the pneumococcal immunization status be determined and documented for each resident upon admission, including education on the benefits and potential side effects of the vaccine. However, this was not adhered to in the case of the resident in question. Interviews with facility staff revealed a lack of clarity and responsibility regarding the resident's immunization status. The Infection Control Preventionist indicated that the responsibility for documenting immunizations lies with the Unit Managers. However, the Unit Manager interviewed was unaware of the resident's pneumonia vaccination status and confirmed the absence of documentation in the electronic medical record. The facility administrator acknowledged awareness of some issues but was not informed of the extent of the deficiency.
Failure to Educate and Document COVID-19 Vaccination for Resident
Penalty
Summary
The facility failed to provide education and offer the COVID-19 vaccine to one of the sampled residents, identified as R19, as per their policy on infection control and immunizations. The policy mandates that residents receive education on the benefits, risks, and potential side effects of the SARS-CoV-2 vaccine before it is offered, and that documentation of the education and the resident's decision is maintained in the medical record. However, a review of R19's clinical record revealed no documentation of the COVID-19 vaccine being offered, administered, or declined. R19, who was admitted with diagnoses including cerebral vascular accident and vascular dementia, had a BIMS score indicating no cognitive impairment, suggesting they were capable of making informed decisions regarding vaccination. Interviews with facility staff, including the Infection Control Preventionist, the LPN Unit Manager, and the Administrator, revealed a lack of clarity and responsibility regarding the documentation and administration of COVID-19 vaccines. The Infection Control Preventionist indicated that unit managers were responsible for immunization documentation, while the LPN Unit Manager could not recall any information about R19's COVID-19 vaccination status. The Director of Nursing confirmed that R19 had neither received the vaccine nor signed a declination form, highlighting a gap in the facility's adherence to its own immunization policy.
Latest citations in Georgia
The facility failed to follow its abuse investigation policy when responding to an allegation that a male resident wandered into a female shared room, allegedly sat on a resident’s bed, inappropriately touched her leg, stared at another resident, and opened the bathroom door to watch a third resident brushing her teeth. The allegation was reported by a cognitively intact resident and involved residents with varying levels of cognitive impairment. The investigation, conducted by the Administrator and former DON, relied only on interviews with a RN and a CNA, did not obtain required written, signed, and dated witness statements, and did not include interviews with other residents to assess their sense of safety. Despite these omissions and incomplete documentation, the facility’s final report concluded the allegation was unsubstantiated.
A resident with protein calorie malnutrition and a terminal prognosis was admitted on hospice with corresponding physician orders and a care plan, but hospice services were not coded on either the admission or quarterly MDS assessments. The MDS Coordinator and two MDS LPNs confirmed that, despite the resident receiving hospice care, Section O of both MDS assessments incorrectly indicated the resident was not on hospice, which the Administrator and DON acknowledged resulted in inaccurate MDS data.
Surveyors found that PTAC unit filters in two resident rooms on one hallway were not maintained free of visible grey, fuzzy debris, despite facility policy requiring regular inspection and cleaning or replacement at least every three months. Across multiple observations on different days, the condition of the dirty filters remained unchanged. The Maintenance Director reported he is responsible for monthly cleaning and checks, including spot checks and inspections in construction areas, and did not dispute the observed dust accumulation when shown. The Administrator confirmed that maintenance staff are responsible for monthly PTAC filter cleaning as part of preventative maintenance and acknowledged that this issue could negatively affect residents’ health and well-being.
A resident with intact cognition and known skin integrity risks reported being left on a bedpan for an extended period and not being adequately cleaned by a CNA. The following shift, another CNA found the resident on soiled linens with a blister on the left upper thigh but did not report this new skin issue to the charge nurse or DON. Subsequent documentation showed development of an open area on the thigh associated with pain, and later NP evaluation identified a larger wound requiring sharp excisional debridement. These events show failure to provide adequate incontinent care and to promptly assess and report a new wound, contrary to the facility’s abuse/neglect prevention policy and CNA responsibilities.
A cognitively intact resident with skin-related diagnoses reported delayed and inadequate incontinent care after using a bedpan, describing prolonged waits for staff response and feeling not properly cleaned by a CNA. The next morning, another CNA found feces-soiled linen and a blister on the resident’s left upper thigh, later documented as a new open area. The resident texted the Administrator stating that a CNA had left feces on her and that she had developed a painful blister, but the Administrator did not report this allegation of neglect to the State Survey Agency as required by facility policy.
A resident with lymphedema and identified risk for pressure ulcers developed a new open wound on the upper thigh, documented by a NP with specific wound measurements. Although the existing care plan included interventions to observe and document skin changes, the care plan was not updated to include this new wound. The Wound Care Nurse and the resident confirmed the wound location, while the MDS Coordinator reported not receiving recent weekly wound reports and only recently learning of the wound. The MDS Coordinator confirmed that the care plan had not been revised in real time as required by facility procedures, resulting in a failure to implement care plan interventions for the newly developed pressure ulcer.
The facility did not complete a required Georgia Criminal History Check System (GCHEXS) fingerprint background check for a CNA, as identified during review of ten employee files with a census of eighty residents. The facility’s abuse-prevention policy required criminal background checks for all employment candidates, but there was no documentation of a fingerprint records check for this CNA. The HR manager, who is responsible for background and fingerprint checks and maintaining employee files, confirmed that the GCHEXS fingerprint check had not been conducted, resulting in a deficiency under F-Tag 600.
Surveyors found that four of six resident shower rooms were not kept free of hazards or adequately cleaned. On one floor, razors were on the floor, dirty gloves and a comb were on a shower bed, floors were stained, an opened gallon of bath soap and a bottle of chemical-resistant spray were present, and a razor and hair clippers were in a bag on the floor along with a shower cap and toothbrush. On other floors, surveyors observed multiple opened containers of skin and hair cleaner, conditioner, and skin ointment, along with a strong urine odor. Unit managers and the Environmental Senior Director stated that CNAs were responsible for cleaning after each resident and that environmental services cleaned shower rooms daily, and acknowledged that items should not be left on the floor and that product containers should be closed.
Surveyors found that staff did not follow standard and transmission-based precautions when handling ice on two floors. On one floor, the ice scoop cover on top of the ice machine had visible black specks near the end of the scoop used to dispense ice. On another floor, the ice scoop was observed submerged in ice and water inside the cooler used to serve residents, despite the unit manager acknowledging that the scoop should not be left in the cooler. The Maintenance Director reported that maintenance cleaned and checked ice machines regularly, while nursing staff were responsible for cleaning scoops and covers. The SDC/Infection Control nurse stated that all staff had been in-serviced on hand hygiene and ice scoop protocol, including that scoops should be stored in a holder after use and never left in the ice.
A resident with multiple serious conditions, moderate cognitive impairment, and total dependence for ADLs was placed in bed with side rails intended to assist with positioning, despite the MDS indicating no bed rail use. Facility records showed no evidence of safe rail spacing or regular inspection of the bed and rails. The assigned CNA, who came on duty late in the evening, last saw the resident around the start of the shift and did not check on him again for several hours, relying on the resident to use a call light. In the early morning, the CNA and an RN found the resident partially out of bed, entrapped in the half side rail, requiring multiple staff to free and reposition him. The resident was unresponsive except for moaning, with altered mental status and respiratory failure documented by EMS and the ER, and later expired at the hospital. The facility’s failure to provide required monitoring and to ensure safe side rail use resulted in neglect and Immediate Jeopardy.
Failure to Thoroughly Investigate Allegation of Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough investigation of an allegation of sexual abuse in accordance with its policy titled “Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating.” The policy required that all allegations be thoroughly investigated, including reviewing documentation and evidence, interviewing any witnesses, interviewing staff on all shifts who had contact with the resident, and completely documenting the investigation, with written, signed, and dated witness statements. A facility-reported incident documented that a male resident was wandering into a female three-bed room, allegedly inappropriately touching one resident, staring at another for a length of time, and then opening the bathroom door and staring at a third female resident while she was brushing her teeth. The allegation was initially reported by a cognitively intact resident (BIMS score 15) and involved another resident with moderate cognitive impairment (BIMS score 8) and a resident with severe cognitive impairment (BIMS score 99). The Administrator reported that the investigation of this incident was conducted by the former DON and herself after the allegation was reported by a RN. She stated that this was not the first time the alleged male resident had wandered into other residents’ rooms and described the allegation as the male resident entering a resident’s room, sitting on the resident’s bed, and allegedly touching the resident’s leg. Staff interviews for the investigation were limited to the RN and a CNA, and the Administrator acknowledged that no written witness statements were obtained, contrary to facility policy. She also confirmed that no additional residents were interviewed to assess their sense of safety following the incident. The facility’s final investigation report concluded that the allegation was unsubstantiated, despite the lack of comprehensive interviews, written statements, and full documentation required by the facility’s abuse investigation policy.
Failure to Accurately Code Hospice Services on MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate completion of the Minimum Data Set (MDS) for a resident receiving hospice services. The facility’s policy on Certification of Accuracy of the MDS requires that appropriate health professionals correctly document residents’ medical, functional, and psychosocial problems using the Resident Assessment Instrument. The resident in question was admitted with diagnoses including protein calorie malnutrition and had a care plan dated 01/09/2026 indicating a terminal prognosis and admission to hospice, with a goal to honor advance directives and provide comfort with dignity. Physician’s orders dated 12/09/2025 also included an order to admit the resident to hospice. Despite this, review of the admission MDS and a subsequent quarterly MDS showed that hospice services were not coded in Section O (Special Treatments, Procedures and Programs), even though both assessments documented a Brief Interview for Mental Status (BIMS) score of five, indicating severely impaired cognition. Interviews with the MDS Coordinator and two MDS LPNs confirmed that the resident had been on hospice since admission and that both the admission and quarterly MDS assessments were incorrectly coded as not on hospice. The MDS Coordinator acknowledged that the MDS should present an accurate clinical picture for a given period and stated that this was a clerical error, resulting in CMS not receiving correct hospice coding for the resident. The Administrator and DON stated their expectation that MDS assessments accurately reflect residents’ services and confirmed that failure to code hospice in the MDS results in an inaccurate reflection of the data.
Failure to Maintain Clean PTAC Unit Filters in Resident Rooms
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to maintain Packaged Terminal Air Conditioner (PTAC) unit filters in a safe, clean condition in two resident rooms on the Sapphire Hallway. The facility’s written policy titled "Instructions" requires that air filters be removed and inspected for cleanliness, washed or replaced if dirty, and at a minimum replaced or thoroughly cleaned every three months. During multiple observations in one room on 3/22/2026, 3/24/2026, and 3/25/2026, the PTAC unit filter was noted to have visible grey, fuzzy debris accumulation, with no change in condition across all three observations. Similar repeated observations on those same dates in another room showed the PTAC unit filter also contained visible grey, fuzzy debris accumulation that remained unchanged. In an interview, the Maintenance Director stated he is responsible for cleaning and checking the PTAC filters monthly, including conducting monthly checks and random inspections in areas where construction is occurring, and confirmed that the maintenance department is responsible for ensuring filters are clean and functioning properly. He also stated that expectations include spot checks of PTAC units. However, during an observation of one of the affected rooms in his presence, dust accumulation was again observed on the PTAC unit filter, and he did not dispute the finding. In a separate interview, the Administrator stated that the maintenance department is responsible for cleaning PTAC filters, which are supposed to be cleaned monthly, and that her expectation is for preventative maintenance to be completed monthly and as needed, noting that a potential negative outcome is the impact on residents’ health and well-being.
Neglect of Incontinent Care and Delayed Wound Reporting Leading to Thigh Wound
Penalty
Summary
The deficiency involves the facility’s failure to prevent neglect and to assess and provide timely wound and incontinent care to a cognitively intact resident with known skin integrity risks. The resident, who had diagnoses including a disorder of the skin and subcutaneous tissue and lymphedema, was care planned as being at risk for pressure ulcer development and skin integrity issues, with interventions directing staff to observe, document, and report any changes in skin status. On a night shift, the resident reported being left on a bedpan for approximately an hour and a half. When the CNA on that shift (CNA BB) assisted with post-toileting care, the resident told her she did not feel adequately cleaned; CNA BB did not recheck or further clean the resident and left the room. The next morning, the resident reported burning in the left upper thigh and informed another CNA (CNA EE) that she had not been cleaned well. During morning care, CNA EE found the pad under the resident soiled with feces and wet with urine and observed a blister on the resident’s left upper thigh, but did not report the new blister to the charge nurse or DON. A subsequent Skin Wound Note documented a new open area on the left posterior thigh with the resident reporting pain while sitting on the bedpan. Later, an NP wound care consult documented that the thigh wound had been present for approximately two weeks per nursing report and measured 3.5 cm x 4.0 cm x 0.2 cm, requiring sharp excisional debridement to remove necrotic tissue and decrease bacterial burden. On observation by the surveyor with the Wound Care Nurse, the left upper thigh area was open to air, shiny pink and granular, about the size of a half dollar. These findings demonstrate that the facility did not follow its abuse/neglect prevention policy and CNA job responsibilities to provide necessary care and to report changes in condition, resulting in neglect of incontinent care and delayed wound assessment and treatment for this resident.
Failure to Report Allegation of Neglect to State Survey Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of neglect to the State Survey Agency (SSA) as required by its own abuse and neglect reporting policy. The facility’s policy, dated 1/2025, states that any complaint, allegation, observation, or suspicion of resident neglect must be immediately communicated to the Abuse Coordinator and promptly investigated and documented, and that all alleged violations involving mistreatment, abuse, or neglect will be thoroughly investigated under the direction of the Administrator in accordance with state and federal law. Despite this, the Administrator acknowledged that an allegation of neglect reported by a resident was not reported to the SSA. The resident involved was cognitively intact, with a BIMS score of 15, and had diagnoses including a disorder of the skin and subcutaneous tissue and lymphedema. The resident reported that during a night shift she requested assistance for incontinent care after using a bedpan and experienced multiple delays before a CNA assisted her. She stated that when the CNA finally provided care, she did not feel adequately cleaned, and the CNA did not verify cleanliness before leaving. The next morning, another CNA found soiled linen with feces and a blister on the resident’s left upper thigh, which the resident reported as burning. A subsequent skin/wound note documented a new open area on the left posterior thigh. The resident texted the Administrator describing that a CNA had left feces on her and that she had developed a painful blister. The Administrator confirmed receiving this text but did not report the allegation of neglect to the SSA, despite being aware it should have been reported.
Failure to Update and Implement Care Plan for Newly Developed Pressure Ulcer
Penalty
Summary
Surveyors identified a failure to implement and update the care plan for a newly developed pressure ulcer for one resident. The facility’s policy "RAI Care Planning Management" requires a comprehensive, accurate assessment and real-time modification of the care plan when changes occur. The resident was admitted with diagnoses including a disorder of the skin and subcutaneous tissue and lymphedema. A recent MDS quarterly assessment showed the resident was cognitively intact (BIMS 15), at risk for pressure ulcer development, and had no unhealed pressure ulcers at that time. The existing care plan, dated 6/6/2024, identified potential for pressure ulcer development and skin integrity issues related to immobility and lymphedema, with interventions to observe, document, and report changes in skin status, including wound size, stage, and signs of infection. Subsequently, a NP wound report documented a new open wound on the resident’s thigh that had been present for approximately two weeks, with specific measurements recorded. During observation and interview, the Wound Care Nurse and the resident confirmed the wound was on the left upper thigh, which differed from the NP report that referenced the right thigh. The MDS Coordinator reported she previously received weekly wound sheets from the Wound Care Nurse but had not received one in about a month, and that the DON was now responsible for emailing the weekly wound report. She verified that the last wound report she received did not include this resident and stated that new wounds should be discussed in the morning management meeting and the care plan updated in real time. The MDS Coordinator confirmed she only recently became aware of the upper left thigh wound and that the resident’s care plan had not been updated to reflect this new wound, resulting in a failure to implement care plan interventions for the newly developed pressure ulcer.
Failure to Complete Required GCHEXS Fingerprint Check for CNA
Penalty
Summary
The facility failed to ensure that a Georgia Criminal History Check System (GCHEXS) fingerprint check was conducted for one CNA among ten employee files reviewed, despite a census of eighty residents and a written policy requiring criminal background checks for all employment candidates. The policy titled "Freedom of Abuse Abuse Prevention Fast Alert" dated 1/2025 states that, as part of pre-employment screening, all candidates must authorize a criminal background check for conviction of crimes. During record review with the Human Resources Manager (HRM), there was no documentation of a fingerprint records check for CNA BB, and the HRM confirmed that this CNA did not have a GCHEXS fingerprint check conducted. The HRM also stated that she is responsible for background checks, fingerprint checks, reference checks, and maintaining employee files. This failure to complete the required fingerprint background check for CNA BB resulted in noncompliance cited under F-Tag 600. No resident-specific medical histories, conditions, or direct resident care events were described in the report related to this deficiency.
Failure to Maintain Safe and Clean Conditions in Multiple Resident Shower Rooms
Penalty
Summary
Surveyors identified a deficiency related to accident hazards and inadequate environmental controls in multiple resident shower rooms. On the 4th floor, observation with the Unit Manager showed four razors on the floor, dirty gloves and a dirty comb on a shower bed, stained/dirty floors, an opened gallon bottle of complete bath soap, and a bottle of chemical resistant spray in the shower room. A razor and hair clippers were found in a black bag on the floor, and a shower cap and toothbrush were lying on the floor. The 4th floor Unit Manager stated that CNAs were supposed to clean up before showering residents and acknowledged that the items found should not be on the floor. The Environmental Senior Director reported that shower rooms were cleaned daily, with responsibilities including cleaning high-touch areas, sweeping and mopping floors, removing linen, and cleaning the area, and stated there had been no complaints about showers not being cleaned. On the 3rd floor, observation with the Unit Manager revealed an open bottle of skin and hair cleaner, an open bottle of conditioner, and an open bottle of skin ointment in the resident shower room. The 3rd floor Unit Manager stated that items in the shower room should be closed and that CNAs were to clean after each resident. On the 2nd floor, observation with the Unit Manager revealed two opened gallon containers of skin and hair cleaner and a strong urine odor in the shower room. The 2nd floor Unit Manager stated that the soap should have a top on it and that CNAs were responsible for cleaning after each resident. These observations and interviews showed that four of six resident shower rooms were not maintained free of hazards and were not cleaned as expected by facility staff, creating the potential for injury and spread of infection as stated in the report.
Improper Ice Scoop Handling and Storage Breaches Infection Control Protocol
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to improper handling and storage of ice scoops on two of four floors. On the 4th floor, observation of the ice scoop and scoop cover showed black specks near the end of the scoop used to put ice in cups, and the scoop cover was located on top of the ice machine. The 4th floor Unit Manager stated that kitchen staff cleaned the scoops once a week and acknowledged that the scoop should be clean. On the 3rd floor, observation of the ice chest/cooler used to serve residents revealed the ice scoop submerged in ice and water. The 3rd floor Unit Manager later confirmed that the ice scoop was not supposed to be left in the cooler. The Maintenance Director reported that maintenance staff were responsible for cleaning the ice machines, which were checked weekly and monthly, while nursing staff were responsible for cleaning the ice scoops and covers. The Staff Development Coordinator/Infection Control staff stated that all staff had been trained in infection control procedures, including hand hygiene and handling of the ice scoop and holder, and that staff had been educated that the ice scoop should be placed in the scoop holder after use and never left in the ice. Documentation in the maintenance logbook showed monthly checks and cleaning of all four ice machines, and the ice machine cleaning log showed that the ice machines on the 2nd, 3rd, and 4th floors and in the kitchen had been cleaned on specific dates. Staff training records indicated that an in-service on handwashing and ice scoop protocol had been provided for all staff.
Neglect Related to Inadequate Supervision and Unsafe Side Rail Use Leading to Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect related to inadequate supervision and oversight of side rail use, resulting in entrapment. Facility policies on Abuse, Neglect and Exploitation required protections to prevent neglect, defined as failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. The policy on Proper Use of Bed Rails required a person-centered approach, attempts at alternatives before bed rail use, and ensuring correct installation, use, and maintenance of bed rails, including attention to entrapment risk. For this resident, the Medicare 5-day MDS indicated moderate cognitive impairment (BIMS score of 8), total dependence on staff for all ADLs, and documented that bed rails were not used, while an admission assessment documented side rails were placed to assist with movement in bed. Facility records showed no evidence that safe rail spacing and regular inspection of side rails and beds had been completed. The resident had multiple serious medical diagnoses, including acute and subacute infective endocarditis, end stage renal disease, hemiplegia and hemiparesis following cerebral infarction, bacteremia, and cervical disc degeneration, and was dependent on staff for all ADLs. Nursing staff last observed the resident at 12:46 am when a sponge bath was provided; there was no documented monitoring or ADL assistance between 12:46 am and 4:30 am. The assigned CNA reported coming on duty at 11:00 pm, seeing the resident up with the bed in a low position, placing the call light in the resident’s hands, and not seeing or checking the resident again until approximately 4:30–5:00 am, stating that the resident did not press the call light during that time. Around 5:00 am, the CNA requested help from the RN, reporting that the resident needed assistance. The RN found the resident with the lower part of his body hanging off the bed and the upper body still on the bed, with his elbow wedged into the half side rail, requiring three staff to reposition him back into bed. The RN stated the resident, who was quadriplegic, was no longer as alert as when put to bed, did not respond to sternal rubs, had open but unfocused eyes, and was not verbally interactive. The CNA described finding the resident on his knees, all the way out of bed, with one hand tangled in the side rail, and noted that he was moaning but not talking after being returned to bed. Progress notes documented that EMS was called for evaluation and treatment due to the resident’s condition, and hospital ER records indicated he arrived with altered mental status and respiratory failure, agonal respirations, and a GCS of 3. The facility’s Maintenance Director stated bedrails had been checked the prior year but could not provide proof, and requested documentation of safe rail spacing and regular inspection was not provided.
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