Camellia Health & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Claxton, Georgia.
- Location
- 700 East Long Street, Claxton, Georgia 30417
- CMS Provider Number
- 115598
- Inspections on file
- 16
- Latest survey
- December 9, 2025
- Citations (last 12 mo.)
- 3 (2 serious)
Citation history
Health deficiencies cited at Camellia Health & Rehabilitation during CMS and state inspections, most recent first.
A resident with severe contractures, blindness, and total dependence on staff for ADL care was provided in-bed care by a CNA using only one-person assistance, contrary to the care plan's requirement for two-person assistance. During this care, the resident fell from the bed, sustained a head injury, and was later pronounced deceased. Staff interviews revealed confusion and inconsistency in following care plan requirements for assistance levels.
A resident with severe contractures, blindness, and total dependence on staff for ADLs was not provided with the required two-person assistance for bed mobility. Instead, a CNA performed care alone, during which the resident rolled off the bed, sustained a head injury, and was later pronounced deceased. Staff interviews revealed inconsistent adherence to care plans specifying assistance levels.
The facility did not maintain an effective pest control program, resulting in widespread roach infestations in resident rooms, a guest bathroom, and the kitchen. Staff interviews revealed that pest control was not called for additional visits despite ongoing issues, and the pest control technician faced barriers to accessing needed areas. A resident reported finding bugs in food and using bug spray, while staff confirmed the persistent problem.
Three residents with mobility and skin integrity risks were found using wheelchairs with torn or missing armrests and backs, despite facility records indicating regular inspections. Staff, including an LPN and CNA, confirmed the poor condition of the wheelchairs and acknowledged the potential for skin tears. The maintenance staff later admitted that inspection documentation was inaccurate, and the deficiencies were not identified or addressed.
A resident with severe malnutrition and anemia experienced a significant change in condition, including low oxygen levels, but the family was not notified as per facility policy. The resident's daughter, distressed by the lack of communication, requested hospital transfer, where the resident later passed away. Interviews confirmed the lapse in communication by the nursing staff.
Failure to Follow Care Plan for Dependent Resident Results in Fatal Fall
Penalty
Summary
A deficiency occurred when the facility failed to follow the care plan for a resident who was totally dependent on staff for activities of daily living (ADL) care, including bed mobility and transfers. The resident had significant medical needs, including contractures in multiple joints, blindness, immobility, impaired cognition, muscle weakness, and an inability to care for herself. The resident's care plan and Minimum Data Set (MDS) assessment specified that she required two-person assistance for bed mobility, bathing, and transfers. Despite these documented requirements, a Certified Nursing Assistant (CNA) provided care to the resident with only one-person assistance while giving a bed bath and changing linens. During this process, the resident rolled out of bed, fell to the floor, and sustained a head injury. The CNA called a Registered Nurse (RN), who assessed the resident and found a laceration on her head and was unable to obtain vital signs. Emergency Medical Services were called, and the resident was pronounced deceased upon their arrival. Interviews with staff revealed inconsistencies in understanding and following the plan of care, with some staff relying on memory or assumptions rather than verifying the required level of assistance in the care plan. Some staff believed that only one person was needed for certain in-bed care tasks, despite the care plan's requirement for two-person assistance. The failure to adhere to the care plan directly resulted in the resident's fall and subsequent death.
Removal Plan
- R1 is no longer at the facility.
- Investigation initiated and the associate providing care to R1 was removed from the schedule. The associate received education regarding adhering to the plan of care and the support staff needed for ADL care by the DON. Validation of staff education and competency was completed by the DON.
- In-service education was initiated for all nursing staff regarding adhering to the plan of care and the support staff needed for ADL care. Education included how to access the level of care required on the POCs, bed mobility, plan of care, and residents' alerts. DON, ADON, and nurse managers provided education to all RN, LPNs, CNAs, CMAs, and RAI coordinator. No nursing staff shall work until they have completed in-service education. Newly hired associates will be educated upon hire.
- 100% audits of the resident plan of care and ADL plan of care were completed to reflect that all residents who require assistance with bed mobility were accurate. Audit was completed by Don, Adon, and nurse managers to ensure each resident had the appropriate level of assistance needed for bed mobility. All levels of assistance are noted to be accurate.
- The facility's plan of care and ADL plan of care policy were reviewed by the administrator and medical director, with no changes required at this time.
- Audits of staff providing care by the residents' plan of care are being monitored weekly by DON, ADON, Nurse Managers, and Charge nurses and will continue weekly for six weeks across all shifts to include the associate involved in providing direct care to R1, then monthly for two months, and/or when compliance is achieved or maintained.
- An Adhoc Quality Assurance Process Improvement (QAPI) meeting led by the administrator was held and a performance improvement plan was developed and re-evaluated for F656. A root cause analysis was conducted, and no trends were identified; it was determined to be an isolated incident. The Administrator, DON, Medical Director, Director of Regulatory and Quality Services, ADON, Resident Care Coordinator, Social Service Director, Activity Director, Healthcare Navigator, Human Resource partner, Rehab Director, Schedule Coordinator, and housekeeping supervisor were in attendance.
- All corrective actions were completed. The facility alleges that the IJ was removed.
Failure to Provide Required Bed Mobility Assistance Resulting in Resident Fall and Harm
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's disease, chronic pain, muscle weakness, severe contractures, lack of coordination, and blindness was not provided with adequate bed mobility assistance. The resident was completely dependent on staff for all activities of daily living and required two-person assistance for bed mobility, as documented in the care plan and the ADL plan of care. Despite this, a Certified Nursing Assistant (CNA) provided care with only one-person assistance while changing linens after bathing the resident. During this process, the CNA was on the opposite side of the bed, pulling sheets and pads, and observed the resident roll off the bed. Following the fall, a Registered Nurse (RN) was called to assess the resident and found a laceration on the top of the resident's head and was unable to obtain vital signs. Emergency Medical Services were called, and the resident was pronounced deceased upon their arrival. The incident was reported to the State Survey Agency by the Director of Nursing (DON), who also conducted an internal investigation, collected statements from involved staff, and reviewed the care plan and staff education records. Interviews with facility staff revealed inconsistencies in understanding and following the required level of assistance for bed mobility. Some staff referenced the plan of care for guidance, while others relied on their experience or knowledge of the residents. The care plan and ADL documentation clearly indicated the need for two-person assistance, but this was not followed at the time of the incident, resulting in a fall and subsequent harm to the resident.
Removal Plan
- R1 is no longer at the facility.
- Investigation initiated and the associate providing care to R1 was removed from the schedule. The associate received education regarding adhering to the plan of care with repositioning patients and the support staff needed for ADL care by the DON. Validation of associate education and competency was completed by the DON.
- In-service education was initiated for all nursing staff and was completed regarding falls management, adhering to the plan of care with repositioning patients and the support staff needed. Education included how to access the level of care required on the POCs and turning and repositioning, bed mobility, plan of care, and residents' alerts. The facility's fall management program was reviewed. Education was provided by the Administrator, DON, ADON, and nurse managers. All RN, LPN, CNAs, CMAs, and RAI coordinator have been in-service, which totals 100%. No nursing staff shall work until they have completed in-service education. Newly hired associates will be educated upon hire.
- Audit was completed by DON, ADON, and nurse managers on residents with falls to ensure the plan of care is being followed. No revisions needed after review.
- 100% audit completed of residents' plan of care by DON, ADON, and nurse managers to ensure each resident had the appropriate level of assistance needed for bed mobility. All levels of assistance are noted to be accurate.
- The facility's plan of care and ADL plan of care policy were reviewed by the administrator and medical director, with no changes required at this time.
- Audits of staff providing care by the residents' plan of care are being monitored weekly by DON, ADON, Nurse Managers, and charge nurses and will continue weekly for six weeks across all shifts to include the associate involved in providing direct care to R1.
- An ADHOC QAPI meeting led by the administrator was held and a performance improvement plan was developed and re-evaluated for F689. A root cause analysis was conducted, and no trends were identified; it was determined to be an isolated incident. CNA followed the plan of care. The interventions implemented included the PIP review, a review of the fall Program with no changes, and a process for adhering to the plan of care, which involved repositioning patients and the support staff needed.
- All corrective actions were completed. The facility alleges that the IJ was removed.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program as evidenced by widespread observations of roaches in multiple resident rooms, a guest bathroom, and the kitchen. Direct observations included roaches emerging from behind and inside an oxygen concentrator, inside a nightstand drawer, on windowsills, and on the walls and floors of several rooms. In the kitchen, roaches were seen in the room with the refrigerators. Review of the pest control maintenance log showed that routine pest control visits were scheduled, but there were gaps in addressing ongoing infestations. Interviews with staff and residents revealed ongoing issues with roaches for several months. The Maintenance Director and Administrator both acknowledged that it was the Administrator's responsibility to call pest control for additional visits, but this had not been done. The Pest Control Technician reported being unable to access certain areas due to locked doors or staff reluctance to move residents, and noted a persistent leak in the kitchen that contributed to the infestation. A resident reported finding bugs in her food and keeping bug spray to kill roaches, while a housekeeping aide confirmed the ongoing problem.
Failure to Maintain Wheelchairs in Good Repair for Multiple Residents
Penalty
Summary
The facility failed to maintain wheelchairs in good repair for three out of four residents observed, resulting in wheelchair armrests and backs that were missing, torn, or tattered. Observations during the initial tour revealed that one resident's wheelchair had a tattered and torn right armrest and back cover, with the back cushion cover not connected and missing a screw. Two additional wheelchairs, found in the hallway near resident rooms, were observed to have discolored tape, missing armrests, and tattered or torn back cushions and armrests. These deficiencies were confirmed by staff, including an LPN and a CNA, who acknowledged that the damaged areas could potentially cause skin tears. Record reviews indicated that the affected residents had diagnoses such as difficulty in walking, neuropathy, peripheral vascular disease, radiculopathy, arthritis, and type 2 diabetes. Their care plans identified them as being at risk for skin impairment, skin breakdown, and skin tears due to their medical conditions and fragile skin. Each resident's care plan also documented the use of a wheelchair as special equipment, further emphasizing the importance of properly maintained mobility devices. Interviews with staff revealed inconsistencies in the facility's equipment inspection and maintenance practices. The Director of Nursing stated that wheelchairs were checked before each use and that CNAs were responsible for notifying maintenance of any issues. However, the Maintenance Assistant/Floor Technician later admitted that the documentation of monthly wheelchair inspections was incorrect, despite records indicating that inspections had been marked as completed. The observed deficiencies in wheelchair condition were not identified or addressed through the facility's documented inspection process.
Failure to Notify Family of Resident's Condition Change
Penalty
Summary
The facility failed to notify the responsible party of a resident's change in condition, which was a deficiency identified during the survey. The resident, who had multiple diagnoses including severe protein calorie malnutrition and iron deficiency anemia, was admitted to the facility and was under hospice care. On a particular day, the resident was noted to be very weak with low oxygen saturation levels, prompting the application of supplemental oxygen. Despite the facility's policy requiring notification of significant changes in a resident's condition, the resident's daughter was not informed of these changes by the nursing staff. Interviews with the resident's daughter and facility staff revealed that the daughter was distressed over not being notified, as she had been in the past. The LPN who applied the oxygen reported informing the nursing supervisor, who was supposed to notify the family but did not. The Director of Nursing acknowledged that the family should have been notified. The resident's daughter eventually requested hospital transfer due to the low oxygen levels, and the resident passed away the following day at the hospital.
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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