Carrollton Crossing Of Journey Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Carrollton, Georgia.
- Location
- 2327 North Highway 27, Carrollton, Georgia 30117
- CMS Provider Number
- 115368
- Inspections on file
- 19
- Latest survey
- September 9, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Carrollton Crossing Of Journey Llc during CMS and state inspections, most recent first.
A male resident with severe cognitive impairment entered the room of a female resident, also severely cognitively impaired, and inappropriately touched her upper thigh while trying to remove her bed covers. This incident was observed by a CNA, reported, and substantiated by facility investigation, revealing a failure to protect the resident from sexual abuse.
A resident with diabetes and severe cognitive impairment experienced a critically low blood sugar level that was not properly documented or addressed according to the facility's blood sugar protocol. The resident became unresponsive, required IM glucagon, and was transferred to the ER for further treatment. Staff interviews confirmed a lack of documentation and adherence to protocol in managing the resident's hypoglycemic episode.
Surveyors found that kitchen equipment, storage shelves, and food contact surfaces were unclean, with accumulations of food debris and grease. Dietary staff did not consistently label, date, or cover stored food and beverages, and some food items were left open and unprotected in storage areas. The ice machine and microwave were also found to be unclean. These failures were confirmed by the DM and Administrator and were not in accordance with facility policies.
Surveyors identified multiple infection control deficiencies in the laundry area, including a gap under the exterior door, broken wallboard with exposed insulation, debris buildup on air vents and floors, uncleanable unfinished molding, and soiled equipment such as reusable gloves and a floor fan. The Laundry Supervisor confirmed the need for repairs and cleaning.
Several cognitively intact residents reported receiving cold meals, especially at breakfast, with specific complaints about cold eggs, breakfast meat, and grits. Although food left the kitchen at proper temperatures, it was served on unheated plates and transported on a non-heated cart, resulting in cold food by the time it reached residents. Both a surveyor and an LPN confirmed the food was cold, and the Dietary Manager stated that available equipment to keep food hot was not used.
A resident with severe cognitive impairment and multiple diagnoses was not assessed for self-administration of medications, as required by facility policy, before medications were left at the bedside. There were no physician orders or care plan documentation authorizing self-administration, and the ADON confirmed the resident was not able to self-administer medications after pills were found on the resident's nightstand.
A resident with severe cognitive impairment was started on a new medication for OCD-related behaviors without prior notification to the responsible party. Documentation and interviews confirmed that the nurse did not inform the responsible party before administering the medication, and this omission was only discovered later by the ADON.
Two residents, both with significant cognitive and psychiatric conditions, were involved in a physical altercation in which they hit each other in the arm. Facility policy requires protection from abuse by anyone, including other residents, but the incident occurred, and both residents later blamed each other. No injuries were found on assessment, but the facility did not prevent the physical abuse from taking place.
A resident with severe cognitive impairment reported a possible abuse incident to an agency LPN, but the facility did not notify the State Agency as required by policy. The delay in reporting meant the allegation was not investigated promptly.
Two residents did not have comprehensive care plans reflecting their current needs. One resident with dementia and moderate cognitive impairment lacked a dementia care plan, while another with severe cognitive impairment and a newly identified sacral wound did not have the wound addressed in the care plan. An LPN confirmed these omissions.
A resident with Huntington's Disease and severe cognitive impairment, identified as a fall risk, slid off the bed while being changed by a CNA. The ADON completed the fall investigation by reviewing only the nurse's documentation and did not collect statements from the staff involved, resulting in an incomplete investigation.
A resident with ESRD and acute kidney failure who required dialysis did not have Dialysis Communication Forms completed by staff for multiple treatment dates, as required by facility policy. Interviews with the resident, ADON, DON, and RNC confirmed that the forms, which are essential for exchanging care and medication information between the facility and the dialysis center, were not filled out as expected.
A medication error rate above five percent was identified when an LPN administered incorrect doses of Allopurinol and Seroquel to a resident with gout and schizoaffective disorder. The LPN gave only half the prescribed dose of Allopurinol and the wrong dose of Seroquel during the morning pass, contrary to physician orders and facility policy.
A resident with diabetes was not served cereal at breakfast as specified on their tray slips and the facility's planned menus. Despite clear documentation and staff acknowledgment that cereal should have been provided, the resident did not receive it on multiple occasions, and staff confirmed the omission. This failure to follow the planned menu could have affected the nutritional needs of all residents receiving meals from the kitchen.
Three diabetic residents with physician orders for bedtime snacks did not consistently receive them, as confirmed by resident interviews and staff statements. Facility policy required snacks to be provided and labeled for diabetic residents, but the kitchen often failed to supply enough snacks or label them appropriately, resulting in some residents missing their prescribed bedtime snacks.
Failure to Protect Resident from Sexual Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a male resident with severe cognitive impairment entered the room of a female resident, who was also severely cognitively impaired, and inappropriately touched her upper thigh while attempting to remove her bed covers. This incident was observed and reported by a CNA, who redirected the male resident back to his room. Both residents had diagnoses including dementia, and the female resident was noted to have a BIMS score indicating severe cognitive impairment. The event was documented in the residents' progress notes and substantiated by the facility's investigation records. The facility's policy on abuse, neglect, exploitation, mistreatment, and misappropriation of resident property states a commitment to preventing abuse. However, the incident demonstrated a failure to protect the female resident from sexual abuse by another resident. The DON and Administrator confirmed the substantiated incident and acknowledged the expectation that all residents should remain free from abuse.
Failure to Respond and Document Care for Severe Hypoglycemia
Penalty
Summary
A resident with a diagnosis of type 2 diabetes mellitus and severe cognitive impairment was admitted to the facility and had a care plan in place for diabetes management, including monitoring for hypoglycemia and following a blood sugar protocol. On the date of the incident, the resident's blood sugar was documented at 45 mg/dl, but there was no documentation of the nurse's response to this low reading in the electronic medical record. The facility's blood sugar protocol required specific interventions for low blood sugar, including administration of oral glucose or IM glucagon and rechecking blood sugar, but the records did not show these steps were followed or documented. Later, the resident was found unresponsive and diaphoretic, with a glucose level of 39 mg/dl. Oral glucose was attempted but the resident was too unresponsive, so IM glucagon was administered. The resident remained poorly responsive and was transferred to the emergency room, where further treatment was required for recurrent hypoglycemia. Interviews with staff revealed a lack of documentation regarding the nurse's actions in response to the low blood sugar, and the interim DON confirmed that the expectation was for staff to follow the blood sugar protocol and notify the physician as required.
Failure to Maintain Kitchen Sanitation and Proper Food Storage
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen and food service areas regarding cleanliness and food storage practices. The kitchen's two convection ovens, deep fat fryer, steamer, storage shelves, and large manual can opener were found with heavy accumulations of dried, burned, or sticky food substances and grease. Food storage containers and lids were stored directly on unclean shelves, and the walk-in refrigerator's shelving units were also unclean. The main dining room's ice machine contained a black mold-like substance, and the microwave oven had a heavy accumulation of dried food spills and debris. These conditions were confirmed by the Dietary Manager and the Administrator during interviews. Additionally, dietary staff failed to properly label, date, and cover food and beverages stored in the kitchen. Unlabeled and undated items included a large pan of Sheppard's pie, cooked broccoli, cups of juice, ham sandwiches, an opened package of ham slices, an opened package of shredded cheese, and an opened bag of lettuce. Bread storage racks contained opened and undated packages of hamburger buns, and a food storage bin held an open, uncovered 25-pound bag of flour. In the walk-in freezer, large bags of frozen potato cakes, a box of biscuits, and a box of chicken tenderloins were stored open and unprotected from contamination. These issues were acknowledged by the Dietary Manager during the inspection. Facility policies required all kitchen and dining areas, equipment, and utensils to be kept clean and sanitized, and for all food products to be labeled and dated appropriately. The observed failures to maintain cleanliness and proper food storage practices were in direct violation of these policies, creating an environment that could potentially affect all residents consuming food prepared in the facility's kitchen.
Infection Control Deficiencies in Laundry Area
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's laundry area related to infection prevention and control. There was a three-fourth-inch gap under the exterior door leading into the soiled laundry area, and a section of wallboard was broken with exposed insulation, where pillows were found resting against the insulation. The air vents in the soiled laundry room had visible debris buildup, and exposed steel beams were present. Additionally, the opening between the sorting area and the washing machine room was trimmed with unfinished molding, making the surface uncleanable. Further observations revealed that the floor near the washing machines had heavy debris accumulation, including on the floor and on plastic crates supporting laundry chemical buckets. Reusable rubber gloves were found on the floor behind a bucket of chemicals next to the washing machine. In the drying area, a standing floor fan had heavy debris buildup on its grate. The Laundry Supervisor confirmed the need for repairs and cleaning in these areas.
Failure to Serve Palatable and Hot Food to Residents
Penalty
Summary
The facility failed to serve food that was palatable and at a safe, appetizing temperature to four cognitively intact residents. Multiple residents reported that their meals, particularly breakfast, were served cold, with specific complaints about cold eggs, breakfast meat, and grits. These residents typically ate their meals in their rooms and consistently noted that hot foods were not served at an appropriate temperature. The facility's policies required hot foods to be held at 136 degrees Fahrenheit or above and cold foods at 40 degrees or below until served, with procedures in place for monitoring food temperatures and quality. Observation during a test tray audit confirmed that while food temperatures were acceptable when leaving the kitchen, the meals were served on unheated plates and transported on a cart without a heating element. By the time the last tray was served, the food had become cold, as confirmed by both a surveyor and an LPN who tasted the test tray items. The Dietary Manager acknowledged that the plate warmer was not in use due to a broken suction cup and that available insulated plate holders were not utilized by staff during the meal service.
Failure to Assess Resident Before Allowing Self-Administration of Medications
Penalty
Summary
The facility failed to assess a resident for self-administration of medications before medications were left at the bedside. According to the facility's policy, an interdisciplinary team assessment is required to determine a resident's ability to self-administer medications. The resident in question had diagnoses including dementia, anxiety disorder, hypertension, and major depressive disorder, and was documented as being severely cognitively impaired with a BIMS score of three out of 15. There were no physician orders or care plan documentation permitting the resident to self-administer medications. The Assistant Director of Nursing confirmed that the resident was not able to self-administer medications after the resident's sister found a cup of pills on the nightstand in the resident's room.
Failure to Notify Responsible Party of New Medication Order
Penalty
Summary
The facility failed to notify the responsible party (RP) of a resident with severe cognitive impairment about a new medication order prior to its administration. The resident, who was admitted with diagnoses of dementia and anxiety disorder and had a BIMS score of zero, was prescribed Naltrexone 50 mg daily for obsessive-compulsive disorder (OCD) related behaviors. Documentation in the electronic medical record and nursing progress notes did not show that the RP was informed of the new medication order before it was given. Interviews with the Assistant Director of Nursing (ADON) and Interim Director of Nursing (IDON) confirmed that the nurse responsible for the order did not notify the RP as required. The ADON only became aware of the omission after reviewing the record at a later date. Both the ADON and IDON acknowledged that the RP should have been notified and that this should have been documented in the resident's medical record.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, as required by its Abuse Prevention Program policy. According to the report, two residents with significant cognitive and psychiatric diagnoses, including metabolic encephalopathy, anxiety disorder, bipolar disorder, and depression, were involved in a physical altercation. The incident involved both residents hitting each other in the arm. The facility's policy specifically states that residents must be protected from abuse by anyone, including other residents, and defines physical abuse as actions such as hitting and slapping. A review of the electronic medical record showed that one of the residents involved had a severely impaired mental status, with a BIMS score of six out of 15. Following the altercation, skin assessments indicated that neither resident sustained redness, discoloration, or open areas. Interviews with facility staff confirmed that the residents were immediately separated after the incident, and both residents blamed each other for the altercation. The report documents that the facility did not prevent the physical abuse from occurring between the two residents.
Failure to Promptly Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to ensure that an allegation of abuse was reported promptly to the abuse coordinator/administrator and the State Agency (SA) as required by facility policy. A resident with severe cognitive impairment, as indicated by a BIMS score of 2 out of 15 and diagnoses of dementia and anxiety, reported to an agency LPN that they felt they had been raped. This report was made during the early morning hours, but the facility's records show that the SA was not notified until several days later. Facility policies required immediate reporting of such allegations to both the abuse coordinator/administrator and the SA, but this did not occur. The delay in reporting resulted in the allegation not being investigated in a timely manner.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, as required by its own policy and regulatory standards. For one resident with a diagnosis of dementia and a moderately impaired cognitive status (BIMS score of 12/15), there was no documentation of a dementia care plan in the electronic medical record. This omission was confirmed by an LPN, who stated that the care plan was likely overlooked due to the resident's relatively high BIMS score and a failure to review the diagnosis during the MDS process. For another resident with severe cognitive impairment (BIMS score of 4/15), dementia, and type 2 diabetes, the care plan did not reflect a newly identified sacral wound that was discovered and treated on a specific date. The wound was measured, cleansed, and treated per physician notification, but the care plan was not updated to include this new condition. An LPN confirmed that the care plan should have included this information to address the resident's current needs.
Failure to Thoroughly Investigate Resident Fall
Penalty
Summary
The facility failed to thoroughly investigate a fall experienced by a resident diagnosed with Huntington's Disease, who had both short-term and long-term memory loss and was severely impaired in cognitive skills for daily decision-making. The resident, identified as being at risk for falls due to Huntington's Disease and decreased mobility, slid off the edge of the bed onto the floor while being changed by a CNA. The care plan included education for the resident, family, or caregiver about safety reminders and fall response. However, the Assistant Director of Nursing (ADON) completed the investigation report solely by reviewing the nurse's documentation and did not obtain statements from the CNA or nurse present at the time of the fall, stating she was unaware this was required. This lack of a comprehensive investigation had the potential for the fall not to be thoroughly reviewed, which could allow for repeated incidents.
Failure to Complete Dialysis Communication Forms for Resident Receiving Dialysis
Penalty
Summary
The facility failed to complete required Dialysis Communication Forms for a resident with end-stage renal disease (ESRD) who received dialysis treatments at an outside center. According to facility policy, staff are expected to document and exchange information regarding the resident's care and medication administration through these forms, which are to be completed by both the facility and the dialysis center for each treatment. Review of the resident's electronic medical record and Dialysis Communication Notebook revealed that these forms were not completed on multiple specified treatment dates. Interviews with the resident, the Assistant Director of Nursing (ADON), and the Director of Nursing (DON) confirmed that the process for communication was not followed as required, with the DON stating that nursing staff were expected to complete the forms for each dialysis session. The Registered Nurse Consultant (RNC) also verified that the forms were missing for the listed dates. The resident was cognitively intact and had a care plan in place for ESRD and acute kidney failure, requiring dialysis and medications, but the lack of completed communication forms indicated a failure to ensure effective communication and documentation regarding her dialysis care.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent during medication administration, resulting in an observed error rate of eight percent. During a medication pass, an LPN administered the incorrect doses of two medications to a resident. Specifically, the resident, who had a history of gout and schizoaffective disorder and was cognitively intact, was prescribed Allopurinol 200 mg daily and Seroquel 200 mg twice daily with an additional 400 mg at bedtime. However, the LPN gave only 100 mg of Allopurinol instead of the ordered 200 mg, and administered the 400 mg bedtime dose of Seroquel during the morning medication pass instead of the prescribed 200 mg dose. The errors were confirmed by both the LPN and the Assistant Director of Nursing during interviews. The facility's policy on medication administration, which requires verification of the right resident, medication, dosage, time, and route, was not followed in this instance. The observed failures directly contributed to the medication error rate exceeding the acceptable threshold.
Failure to Follow Planned Menus for Diabetic Resident
Penalty
Summary
The facility failed to follow its planned menus and ensure that a resident with diabetes mellitus received the specified food items as indicated on their meal tray slips. Specifically, the resident was not served cereal at breakfast on multiple occasions, despite the tray slips and planned menus indicating that cereal should have been provided. The resident reported not always receiving cereal as specified, and direct observations confirmed that cereal was missing from the resident's breakfast trays on at least two separate days. The resident also expressed feeling hungry and wanting cereal, which was not provided. Interviews with staff, including a CNA and the Dietary Manager, confirmed that the resident's tray slips called for cereal, and that the kitchen was responsible for ensuring the correct items were served. The Dietary Manager acknowledged that the resident should have received grits or cold cereal according to the menu and tray slips, but this did not occur. The facility's policy required that meals meet residents' nutritional needs and follow the planned menus, but this was not adhered to in the case of this resident, potentially affecting the nutritional intake of all residents receiving meals from the kitchen.
Failure to Consistently Provide Bedtime Snacks to Diabetic Residents
Penalty
Summary
The facility failed to provide a bedtime snack each night for three diabetic residents, despite physician orders and facility policy requiring such snacks for insulin-dependent diabetics. Review of records showed that two of the residents were cognitively intact and one had moderate cognitive impairment. All three residents reported not consistently receiving their prescribed bedtime snacks, with some stating they only received snacks a few times per week. Physician orders for bedtime snacks were present for at least two of the residents, and all three expressed a desire to receive a nightly snack as part of their care. Interviews with staff revealed that the kitchen did not always provide enough snacks for all residents who required them, and snacks were not consistently labeled with resident names, particularly for diabetic residents. Certified Nursing Assistants reported that the kitchen sometimes failed to send enough snacks, and the Dietary Manager confirmed that all diabetic residents should receive a nightly snack, with snacks to be labeled and delivered accordingly. Facility policy also indicated that residents should have access to nourishing snacks throughout the day and night, but this was not consistently implemented.
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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