Chatuge Regional Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Hiawassee, Georgia.
- Location
- 386 Belaire Drive, Hiawassee, Georgia 30546
- CMS Provider Number
- 115701
- Inspections on file
- 20
- Latest survey
- December 4, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Chatuge Regional Nursing Home during CMS and state inspections, most recent first.
The facility administration failed to address allegations of abuse, exploitation, and injury of unknown origin involving residents. The Administrator did not investigate or report incidents such as a personal relationship between a CNA and a resident, an injury of unknown origin, and multiple abuse allegations by staff. These failures were acknowledged by the Administrator, who cited misplaced documentation as a reason for the lack of action.
Two residents were subjected to abuse by CNA staff, with one resident experiencing verbal and physical abuse during a shower, and another being denied access to a bedside toilet. The facility failed to document and investigate these incidents properly, allowing the involved CNA to continue working, leading to Immediate Jeopardy.
A resident with dementia was exploited by a CNA who developed an inappropriate personal relationship with him, including being listed as his emergency contact. The resident's debit cards were declined, raising concerns about financial exploitation. The facility's Administrator failed to thoroughly investigate the allegations, dismissing them as rumors, which led to noncompliance with protecting residents from exploitation.
The facility failed to report incidents of abuse, neglect, and exploitation involving two residents to the SSA. One resident, with moderate cognitive impairment, experienced potential exploitation and sustained an unreported hip fracture. Another resident, cognitively intact, reported neglect when a CNA refused to assist with toileting. These incidents were not reported as required by the facility's policy.
The facility failed to investigate allegations of abuse, exploitation, and an injury of unknown origin involving three residents. One resident was potentially exploited by a CNA, another was verbally abused, and a third was neglected, with no thorough investigations conducted. The administrator confirmed the lack of action, indicating a pattern of inaction in addressing serious allegations.
A resident reported that a CNA did not allow her to use the bedside toilet over a weekend, instructing her to use her pull-up instead. The grievance form was incomplete, with no action taken or follow-up noted. Additionally, the facility lacked a process for anonymous grievance submissions, potentially affecting all residents.
The facility failed to obtain signed informed consents for bed rail use for four residents, despite policy requirements. Residents R1 and R45, who were cognitively intact, reported not being informed of the risks and benefits. For residents R72 and R78, who were rarely or never understood, discussions with family or representatives were documented, but no signed consents were found. The Director of Nursing acknowledged the expectation to attempt alternatives and inform residents of risks, but no consents were provided by the exit conference.
The facility failed to remove expired medications and supplies from storage areas, potentially affecting residents. Expired items were found in the Blue Hall medication room, including Pro-Stat, Co-Q-10, Zinc Sulfate, and others. A phlebotomy cart contained expired vacutainer tubes, and a medication cart had discontinued oxycodone. Staff confirmed these items should have been removed.
The facility failed to serve meals on time for 50 residents, with lunch trays often arriving hours late, affecting those with medical conditions like diabetes and acid reflux. Staff confirmed the delays, citing communication issues between nursing and dietary departments. Family members also expressed concern over the late meal service.
The facility did not ensure the safety of bed rails for 90 out of 104 resident beds, risking potential entrapment or injury. The policy requires assessing the space between mattresses and side rails, but the annual inspection report lacked this review. Maintenance staff confirmed they did not perform safety checks on beds with side rails, contrary to the DON's expectations.
A resident, who was cognitively intact, was not assisted by the facility in obtaining necessary identification for voting, despite expressing the need for help. The Activities Director was aware of the requirement but did not take action until later, as confirmed by the Social Services Director and the DON.
The facility failed to provide written transfer notices to three residents or their representatives during emergent hospital transfers, as required by policy. The Director of Nursing and staff were unaware of the requirement, leading to verbal notifications only. This affected residents who were transferred due to changes in mental status and other symptoms, without receiving the necessary written documentation.
A facility failed to submit an annual MDS assessment for a resident within the required timeframe, as it was submitted over a month late. The MDS Coordinator acknowledged the delay was due to an incomplete audit process, and the facility lacked a specific policy for timely submissions, relying on the RAI Manual guidelines.
The facility failed to conduct care plan conferences for several residents, including those with cognitive impairments, leading to a lack of involvement in care decisions. Additionally, a resident with cerebral palsy did not have updated interventions in their care plan, despite physician orders for specific support measures. Observations confirmed the absence of required support, highlighting a systemic issue in care planning processes.
A facility failed to adhere to physician orders for a resident with cerebral palsy, who required body pillows for torso support due to lack of upper body strength and a gastric feeding tube. Observations revealed the absence of these pillows, and staff interviews indicated a lack of awareness and compliance with the order, potentially risking the resident's safety.
A resident with COPD did not receive proper respiratory care as the nebulizer equipment was not stored in a sanitary manner. The medication chamber was found with medication residue and was not rinsed or bagged as per facility policy. Staff interviews confirmed the failure to follow infection control procedures.
A consultant pharmacist did not identify or report irregularities in a resident's PRN lorazepam prescription, which exceeded the 14-day limit without a documented rationale. Despite facility policy requiring medication regimen reviews, the pharmacist failed to address the issue, and interviews confirmed the absence of necessary documentation.
A facility failed to comply with regulations for PRN antianxiety medication use for a resident with dementia and psychotic disturbance. The resident had a PRN order for lorazepam without a 14-day stop date or documented rationale for extended use. Staff interviews revealed a lack of awareness and documentation regarding these requirements, leading to a deficiency in medication management compliance.
The facility did not post complete daily nurse staffing information, omitting the facility name, census, and total hours worked by nursing staff. Observations and interviews confirmed these omissions, and there was no policy in place to ensure compliance.
Failure to Address Allegations of Abuse and Exploitation
Penalty
Summary
The facility administration failed to provide protective oversight to ensure the highest practicable physical and psychosocial well-being of residents. Specifically, the Administrator did not take appropriate action on several allegations of employee-to-resident abuse, exploitation, and injury of unknown origin. These incidents included a personal relationship between a CNA and a resident, an injury of unknown origin, and multiple allegations of abuse by staff members towards residents. The Administrator did not identify these situations as potential abuse or exploitation, failed to investigate or report them, and did not protect the residents involved. The report highlights specific incidents where the Administrator was informed of potential abuse or exploitation but failed to act. For instance, an allegation of exploitation involving a CNA and a resident was not investigated or reported. Additionally, an injury of unknown origin was not addressed, and allegations of abuse by a CNA towards two residents were not investigated or reported. The Administrator acknowledged these incidents as indicative of abuse but admitted to not reporting them timely or investigating them thoroughly, citing misplaced documentation as a reason.
Failure to Protect Residents from Abuse by CNA Staff
Penalty
Summary
The facility failed to protect two residents from abuse by Certified Nursing Assistant (CNA) staff. One resident, identified as R78, who was severely cognitively impaired with a BIMS score of zero, was subjected to verbal and physical abuse during a shower. A CNA reportedly spoke harshly to R78, threw the resident into a shower chair, and threatened to punch the resident if they vomited. The incident was reported by another CNA, but the facility's investigation was inadequate, with no documentation of the outcome, and the abusive CNA continued to provide care to the resident. Another resident, R107, who was cognitively intact with a BIMS score of 15, filed a grievance after being denied access to a bedside toilet over a weekend. The resident was told to use a pull-up instead, despite having received an enema. The grievance was not properly documented, and the CNA involved continued to work with residents. The Director of Nursing (DON) and the Administrator were aware of the incidents but failed to take appropriate action to protect the residents. The facility's noncompliance with abuse prevention policies led to the identification of Immediate Jeopardy, indicating a situation that could cause serious harm to residents. The facility's failure to document and investigate the incidents properly, along with allowing the involved CNA to continue working, demonstrated a significant lapse in ensuring resident safety and compliance with federal regulations.
Failure to Protect Resident from Exploitation by CNA
Penalty
Summary
The facility failed to protect a resident, identified as R71, from exploitation by a Certified Nurse Aide (CNA 1). R71, who was moderately cognitively impaired with a diagnosis of dementia and delusions, was reportedly involved in a personal relationship with CNA 1. The Administrator documented that CNA 1 was spending excessive time with R71, including staying with him until 2:00 am and holding hands, which crossed professional boundaries. Despite being informed of these concerns, CNA 1 was only reassigned to another hall rather than being suspended or further investigated. The situation escalated when R71 attempted to pay his bill with three debit cards, all of which were declined, leading him to express confusion about who was spending his money. Further investigation revealed that CNA 1 was listed as R71's emergency contact on hospital records. Despite these red flags, the Administrator admitted to not thoroughly investigating the allegations of exploitation, dismissing them as rumors. This lack of action and oversight contributed to the facility's noncompliance with protecting residents from exploitation.
Failure to Report Abuse and Neglect Incidents
Penalty
Summary
The facility failed to report several incidents of abuse, neglect, and exploitation to the State Survey Agency (SSA) as required by their policy. Specifically, two residents were involved in these incidents. One resident, who was moderately cognitively impaired, was involved in a situation with a Certified Nursing Aide (CNA) who spent excessive time in the resident's room and was observed holding hands with the resident, suggesting a potential exploitation. Additionally, this resident left the facility against medical advice and reported issues with his debit cards being declined, indicating possible financial exploitation. Furthermore, the resident sustained a hip fracture from an injury of unknown origin, which was not reported to the SSA. Another resident, who was cognitively intact, reported that a CNA refused to assist him to the bathroom over a weekend, instructing him to use his pull-up instead. This incident of verbal abuse and neglect was also not reported to the SSA. The facility's Administrator confirmed that these incidents were not reported, which constitutes a failure to comply with the facility's abuse reporting policy and state regulations.
Failure to Investigate Abuse and Neglect Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse, exploitation, and an injury of unknown origin involving three residents. For one resident, there was a suspected personal relationship with a CNA, which led to neglect of other residents and potential financial exploitation. Despite reassignment of the CNA, there was no evidence of a thorough investigation into these allegations. Additionally, the resident experienced a fall resulting in a hip fracture while on a leave of absence, but the facility did not investigate the injury's origin. Another resident, who was severely cognitively impaired, was reportedly verbally abused by a CNA. Although the administrator claimed to have investigated the incident, the documentation was misplaced, and the CNA continued to provide care without any reported outcome of the investigation. This lack of documentation and follow-up indicates a failure to address the abuse allegations properly. A third resident, who was cognitively intact, reported neglect by the same CNA, who allegedly refused to assist with toileting needs over a weekend. Despite the grievance filed by the resident's family, there was no evidence of an investigation into the abuse allegations. The administrator confirmed the lack of a thorough investigation, highlighting a pattern of inaction in addressing serious allegations of abuse and neglect.
Failure to Resolve Resident Grievance and Lack of Anonymous Submission Process
Penalty
Summary
The facility failed to ensure that grievances were promptly and thoroughly resolved and/or responded to for one resident out of 27 sampled residents. The resident, identified as R107, submitted a grievance form to the Social Services Director, reporting that over a weekend, a Certified Nurse Aide (CNA) did not allow her to use the bedside toilet and instructed her to use her pull-up instead. The resident stated she was kept in bed all weekend and did not get up until the following Monday. The grievance form's investigation section noted that the staff member in charge of the resident claimed the resident was advised against using the toilet due to having had an enema and being tired. However, the sections for 'Action Taken' and 'Person making the complaint has been informed of results' were left blank, indicating a lack of follow-up and resolution. Additionally, the facility did not have a process in place for residents to file grievances anonymously, which could potentially affect all residents. During interviews, the Administrator acknowledged the absence of an anonymous grievance submission process and confirmed that grievances should be directed to the appropriate department for resolution. The Director of Nursing emphasized the importance of completing grievance forms and stated that the Social Services Director would be involved in every grievance. Despite these acknowledgments, the facility's grievance policy was not effectively implemented, as evidenced by the incomplete handling of R107's grievance.
Failure to Obtain Informed Consent for Bed Rail Use
Penalty
Summary
The facility failed to ensure that informed consents were signed prior to the use of bedrails for four of the 27 sampled residents. The policy titled 'Proper Use of Side Rails' requires that consent for side rail use be obtained from the resident or legal representative after presenting potential benefits and risks. However, for residents R1, R45, R72, and R78, there were no signed informed consents found in the electronic medical records (EMR), despite documentation indicating that risks and benefits had been discussed. Resident R1, who was cognitively intact, expressed dissatisfaction with the bed rails, stating that he was not informed of the risks and benefits. Similarly, resident R45, also cognitively intact, reported that no one had reviewed the risks and benefits of the bed rail with him. For residents R72 and R78, who were rarely or never understood, the facility documented discussions with family or representatives, but again, no signed consents were found in the EMR. Observations confirmed the presence of bed rails in use for these residents. The Director of Nursing acknowledged the expectation that alternatives to side rails should be attempted first, and that residents should be assessed and informed of risks and benefits. Despite this, no signed consents were provided for any of the four residents by the time of the exit conference, indicating a failure to adhere to the facility's policy and potentially placing residents at risk of injury, entrapment, or death.
Expired Medications and Supplies Not Removed
Penalty
Summary
The facility failed to ensure that expired medications and supplies were removed from their storage areas, which could potentially affect any resident who might be administered these expired items. During an observation in the Blue Hall medication room, several expired medications were found, including Pro-Stat, Co-Q-10, Zinc Sulfate, L-Methylfolate Calcium Tablets, Omeprazole, Pink Bismuth, Saccharomyces Boulardii, Iron supplement liquid, and Centrum Adults. A Registered Nurse confirmed the presence of these expired medications, acknowledging that they should have been given to the Director of Nursing for destruction. Additionally, a Licensed Practical Nurse stated that expiration dates should be checked upon receiving medications from the pharmacy, and that night shift nurses were responsible for checking for expired medications. Further observations revealed expired phlebotomy supplies on a cart located at the nurses' station, including a black top vacutainer tube and a container of light blue top vacutainer tubes. A Registered Nurse verified these items were still available for use. Additionally, a medication cart inspection revealed a card of discontinued oxycodone, which should have been removed the day it was discontinued. The Director of Nursing confirmed that expired medications should not be available for use and should be removed immediately.
Consistent Delays in Meal Service for Residents
Penalty
Summary
The facility failed to serve meals according to resident preferences and designated meal times for 50 residents on the green and pink halls. Observations and interviews revealed that lunch trays were consistently delivered late, sometimes as late as 2:15 pm, despite the designated meal time being 12:00 pm. Residents, including those with medical conditions such as diabetes and acid reflux, expressed concerns about the impact of late meals on their health. Staff interviews confirmed the consistent delay in meal delivery, with some trays arriving as late as 3:00 pm, which interfered with their ability to complete other resident care tasks. The Registered Dietician and Dietary Manager acknowledged the designated meal times but did not provide a policy for meal service. The Dietary Manager cited a lack of communication between nursing and dietary staff as a reason for the delays. The Director of Nursing stated that meal service should be timely throughout the day. Unit Managers were unaware of the extent of the delays and agreed that receiving meals at 2:00 pm was too late, impacting other resident care. Family members also noted the late meal service, expressing concern for their relatives' well-being.
Failure to Inspect Bed Rails for Safety
Penalty
Summary
The facility failed to ensure the safety of bed rails for 90 out of 104 resident beds, which could potentially lead to serious injury due to entrapment or other resident injuries. The policy titled Proper Use of Side Rails, revised in December 2016, mandates that the space between the mattress and side rails be assessed to reduce the risk of entrapment. However, the facility's Nursing Home Inspection Report Upon Receipt of Equipment, which is completed annually, did not include a review of bed rails for secure attachment or gaps, as recommended by the FDA guidelines. Interviews conducted during the survey revealed that the maintenance staff did not perform safety checks on beds with side rails. The Director of Nursing confirmed that the expectation was for maintenance to inspect the beds, including bedrails, for safety and security. A list compiled by a Restorative Nurse Aide indicated that 90 residents had one or two side rails on their beds, highlighting the widespread nature of the issue within the facility.
Failure to Assist Resident in Obtaining Voting Identification
Penalty
Summary
The facility failed to assist a resident, identified as R56, in obtaining identification necessary for voting, which compromised the resident's right to vote. R56, who was cognitively intact as indicated by a perfect score on the Brief Interview for Mental Status (BIMS), expressed the need for assistance in renewing his identification card to vote. During an interview, R56 stated that he had previously attempted to vote with a copy of his identification card, which was not accepted, resulting in his vote not being counted. Despite the resident's request for help, the Activities Director (AD) acknowledged awareness of the need but had not taken any action to assist R56 until later. The Social Services Director (SSD) and the Director of Nursing (DON) confirmed that the AD was responsible for ensuring the resident's identification card was updated.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide written transfer notices to three residents (R1, R72, and R101) or their representatives during emergent hospital transfers. This deficiency was identified through record reviews and interviews, revealing that the facility did not comply with its own policy, which mandates written notification containing specific information such as the reason for transfer, effective date, location, appeal rights, and contact details for the State Long Term Care Ombudsman. The Director of Nursing and staff were unaware of the requirement for written notices, as they only informed residents and their families verbally. Resident R1, who was cognitively intact, was transferred to the hospital due to a change in mental status and other symptoms, but neither he nor his representative received a written notice. Similarly, R72 was transferred following a change in mental status and other symptoms, with only a phone notification to the representative. R101 was sent to the ER for labored breathing without a written notice provided to him or his representative. Interviews with the Director of Nursing and a Licensed Practical Nurse confirmed the lack of written notifications, indicating a systemic issue in the facility's transfer process.
Late Submission of MDS Assessment
Penalty
Summary
The facility failed to ensure that an annual Minimum Data Set (MDS) assessment for a resident was submitted within the required 14 days of completion to the Centers for Medicare and Medicaid Services (CMS) Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) System. The deficiency was identified during a review of the resident's assessment data, which revealed that the assessment reference date (ARD) for the last comprehensive MDS was 4/11/2024, but it was not submitted until 5/30/2024. This delay was confirmed by the MDS Coordinator, who acknowledged that the assessment was closed and the care plan signature was present, but the final audit to close it was not completed, leading to the late submission. The MDS Coordinator and the Director of Nursing (DON) both confirmed that the facility did not have a specific policy regarding the timely submission of assessments, relying instead on the guidelines provided in the Resident Assessment Instrument (RAI) Manual. The lack of a formal policy contributed to the oversight, as the MDS Coordinator did not notice the incomplete audit process that delayed the submission. This deficiency had the potential to adversely affect the care planning and provision for the resident involved, as timely and comprehensive assessments are crucial for ensuring appropriate care.
Failure to Conduct Care Plan Conferences and Update Care Plans
Penalty
Summary
The facility failed to ensure that care plan conferences were scheduled and conducted for three residents, leading to a lack of involvement in care decisions and potential unmet care needs. Resident 56, who was cognitively intact, was admitted with hemiparesis and had only one care plan conference since admission, which did not involve him in planning his care. Resident 44, also cognitively intact, was admitted with dementia and seizure disorder and had only two care plan conferences since admission. Resident 17, with Alzheimer's Disease and moderate cognitive impairment, had only one care plan conference since admission. During a group interview, several residents, including Residents 44 and 17, expressed that they had never been invited to a care plan conference and were unaware of their existence. Additionally, the facility failed to update the comprehensive care plan for Resident 3, who was admitted with cerebral palsy and required specific interventions for torso support due to a lack of upper body core strength and a gastric feeding tube. Despite physician orders for bilateral body pillows to be placed under the fitted sheet for support, observations revealed that Resident 3 was in bed without the pillows on multiple occasions. The MDS Coordinator acknowledged the lack of care plan conferences since COVID and mentioned that a new process would be implemented. The Director of Nursing was unaware of the issue until it was brought to her attention, indicating a systemic failure in conducting care plan conferences.
Failure to Follow Physician Orders for Resident Positioning
Penalty
Summary
The facility failed to follow physician orders for a resident diagnosed with cerebral palsy, who required bilateral body pillows for torso support due to lack of upper body core strength and the presence of a gastric feeding tube. The physician order, dated 9/21/2023, specified that the body pillows should be placed under the fitted sheet when the resident was in bed to help maintain an upright position and potentially prevent aspiration. However, during multiple observations on 6/5/2024 and 6/6/2024, the resident was found in bed without the body pillows in place. Interviews with facility staff revealed a lack of awareness and adherence to the physician's order. A CNA and an LPN both stated they were unaware of the requirement for body pillows under the fitted sheet, and neither had placed them for the resident. Another LPN acknowledged awareness of the order but could not explain why the pillows were not in place or when they had been removed. This oversight in following the physician's orders had the potential to put the resident at risk of aspirating.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to provide respiratory care in accordance with professional standards for a resident diagnosed with chronic obstructive pulmonary disease (COPD). The deficiency was identified through observations, record reviews, and interviews. The facility's policy on the prevention of infection associated with respiratory tasks and equipment was not followed. Specifically, the nebulizer equipment used by the resident was not stored in a sanitary manner. The nebulizer medication chamber was observed to still contain medication and was not rinsed or stored in a plastic storage bag as required by the facility's policy. Interviews with the resident and staff revealed that the nebulizer equipment was placed in a basket behind the resident's bed without being rinsed. The resident mentioned that initial instructions included boiling the mouthpiece and medication chamber after use, which was not being done. A registered nurse confirmed the improper handling of the equipment, acknowledging that it should have been rinsed, dried, and bagged after use. The Director of Nursing also stated that the equipment should be washed with soap and water, dried, and stored in a bag after each use, which was not adhered to in this instance.
Pharmacist Fails to Address PRN Lorazepam Irregularity
Penalty
Summary
The consultant pharmacist failed to identify and report irregularities in the medication regimen review for a resident prescribed PRN lorazepam beyond the 14-day limit without a documented rationale or duration for its continued use. The facility's policy requires the pharmacist to conduct medication regimen reviews and make recommendations based on the resident's health record. However, the pharmacist did not address the lack of a 14-day stop date or request a rationale from the physician for the continued use of lorazepam. The resident, who was admitted with a diagnosis of dementia, had a BIMS score indicating no cognitive impairment and was receiving antianxiety medications. Despite the ongoing prescription for lorazepam, the resident's medication regimen reviews from May 2023 to May 2024 did not include any recommendations from the pharmacist. Interviews with the physician and LPN confirmed the absence of documentation regarding the rationale for the continued use of lorazepam, and the pharmacist acknowledged that the monthly reviews did not address this issue.
Failure to Document Rationale for Extended PRN Antianxiety Medication Use
Penalty
Summary
The facility failed to adhere to regulations regarding the use of PRN orders for antianxiety medication, specifically lorazepam, for a resident diagnosed with dementia and psychotic disturbance. The resident, who was cognitively intact with a BIMS score of 15 out of 15, had a PRN order for lorazepam 0.5 mg three times a day for anxiety, dated from May 9, 2023. The facility's policy requires a 14-day stop date for PRN orders of antianxiety medications, but this was not implemented, and there was no documented rationale for extending the PRN order beyond this period. Interviews with facility staff, including a registered nurse, a physician, and a pharmacist, revealed a lack of awareness and documentation regarding the necessity of a 14-day stop date and the requirement for a documented rationale for continued use. The physician acknowledged the need for documentation due to the resident's Parkinson's disease and related anxiety but had not recorded this justification in the progress notes. The pharmacist was aware of the 14-day requirement but did not address it, leading to a deficiency in the facility's compliance with medication management regulations.
Deficiency in Daily Nurse Staffing Information Posting
Penalty
Summary
The facility failed to ensure that the daily nurse staffing information posted included essential details such as the name of the facility, the facility census, and the total number and actual hours worked by both licensed and unlicensed nursing staff responsible for resident care per shift. During an observation, it was noted that the staffing grid chart displayed in the lobby only showed the number of staff for each category across three shifts but lacked the required information. A review of previous months' postings revealed similar omissions. Interviews with the Human Resources staff and the Director of Nursing confirmed the absence of a policy regarding nurse staff posting and acknowledged that the postings did not meet the expected requirements.
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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