Chulio Hills Health And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Rome, Georgia.
- Location
- 1170 Chulio Road, Rome, Georgia 30161
- CMS Provider Number
- 115287
- Inspections on file
- 18
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Chulio Hills Health And Rehab during CMS and state inspections, most recent first.
Surveyors found that the facility did not maintain a clean and safe environment, with dust-like buildup on ceiling vents and unrepaired ceiling tiles in several halls and common areas. The Administrator, ADON, and DON confirmed the dust accumulation, which could trigger respiratory issues in residents with pre-existing conditions. The Maintenance Director stated that vent cleaning was scheduled quarterly but had not identified the issue during daily rounds.
A resident with multiple medical conditions and recent weight loss began refusing meals and medications, representing a significant change in status. Despite facility policy requiring prompt notification, neither the responsible party nor the Registered Dietician were informed of these ongoing refusals. Staff interviews confirmed the change was new and significant, but documentation and communication to all relevant parties did not occur.
A resident receiving hospice care was not accurately coded as such on the Quarterly MDS assessment, as required. Review of facility policy revealed it did not provide guidance for accurate coding of hospice services, and staff interviews confirmed the omission, which affected the accuracy of the resident's care plan.
A resident with multiple respiratory diagnoses and severe cognitive impairment did not have a care plan addressing oxygen use or respiratory conditions, despite physician orders and MDS documentation indicating the need for oxygen therapy. Staff confirmed the omission and acknowledged the importance of accurate care planning for directing resident care.
A resident with multiple complex medical conditions and severe cognitive impairment, who was fully dependent for care and bed-bound, developed a pressure ulcer during a respite stay. The facility failed to consistently assess, monitor, and document the resident's skin condition, and did not provide or document required wound care after a pressure ulcer was identified, despite physician orders and facility policy requiring such interventions.
A resident with respiratory failure and CHF was not provided oxygen therapy at the physician-ordered rate of 2 LPM via nasal cannula. Observations and staff interviews confirmed the oxygen concentrator was set below the prescribed rate, contrary to facility policy and physician orders. Nursing staff did not ensure the correct flow rate was maintained.
Two residents were not instructed to rinse and spit after receiving corticosteroid inhalers, resulting in a medication error rate above 5%. LPNs failed to follow facility policy and manufacturer instructions, despite clear labeling on the medication packaging. Interviews confirmed staff awareness of the requirement, but the step was omitted during observed medication passes.
A resident with a history of stroke and difficulty eating was not consistently provided with physician-ordered built-up utensils at mealtimes, despite clear documentation and facility policy. The resident often had to request the adaptive equipment from staff, resulting in delays and cold food, as observed and confirmed by staff interviews.
Staff failed to follow infection prevention protocols, including an LPN removing a glove box from a resident's room after wound care and a maintenance assistant not using PPE or performing hand hygiene when exiting a Contact Precautions room for candida auris. The facility also did not review or update its Infection Prevention and Control Program policy annually as required.
The facility failed to maintain an adequate Surety Bond to cover the resident trust fund account balance for three months. The bond was set at $80,000.00, while the account balances exceeded this amount in February, May, and July 2024. The Administrator confirmed the discrepancy and was unsure why the bond amount was not adjusted. The bond amount was based on past balances as recommended by the bond company, potentially affecting 62 residents.
The facility failed to ensure the Dietary Manager was certified in dietary or food service management, as required by policy and CMS guidelines. The DM, promoted from a dietary cook, lacked necessary certifications, although she was in the process of obtaining them. The Administrator expected the DM to obtain Serve Safe certification and eventually become a Certified Dietary Manager, but this had not been achieved. The facility did not use a DM from sister facilities for oversight, and the Registered Dietitian provided monthly guidance.
The facility failed to label and date food items in the dry storage and resident nourishment room, leading to unlabeled grits and resident food items. Ice build-up was found on open strawberries in the walk-in freezer. Additionally, improper sanitization procedures were observed, with dishware submerged for less time than required in the sanitizing solution.
The facility failed to implement a 14-day stop date for psychotropic medications for four residents, as required by its policy. Residents were administered lorazepam and Ativan without a documented stop date, leading to a deficiency in medication management. Despite daily reviews of new orders, the oversight occurred, and the DON acknowledged the error, stating that medications should have been reassessed before reordering.
A facility failed to refer a resident with anxiety and depressive disorders for a PASARR level two review, as required by policy. The resident was cognitively intact and on anti-anxiety and antidepressant medications. The Social Service Director did not resubmit the PASARR, believing it unnecessary due to the primary diagnosis not being a mental health issue. The Administrator expected reviews for major mental health diagnoses, but this was not done, leading to a deficiency.
A medication cart was found unlocked and unattended in a hallway, accessible to residents and unauthorized individuals. The responsible RN acknowledged the oversight, and the facility's policy requires carts to be locked when unattended. The DON noted uncertainty about night shift staff receiving relevant education.
A CNA failed to follow infection control protocols for a resident on Enhanced Barrier Precautions (EBP) due to an indwelling catheter. The CNA used the same washcloth for different body areas and did not change the basin water, contrary to facility policy. Additionally, the CNA did not wear a gown as required, despite signage and training indicating the need for PPE during high-contact care activities.
Failure to Maintain Clean and Safe Environment Due to Dust Accumulation and Damaged Ceiling Tiles
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, functional, sanitary, and comfortable environment in multiple areas, including the 100, 200, and 300 Halls, the common area near the nurse station, and the lobby. Specifically, there was a delay in repairing damaged ceiling tiles and a noticeable accumulation of dust-like material on ceiling vents. The facility's policy on cleaning and disinfection required regular cleaning of environmental surfaces and wet dusting of horizontal surfaces with EPA-registered disinfectant, but these standards were not met as evidenced by the visible dust and unrepaired ceiling damage. During interviews and observations with the Administrator, ADON, and DON, all confirmed the presence of dust accumulation on vents throughout the facility, acknowledging that such buildup could provoke allergic reactions and respiratory distress in residents with pre-existing respiratory conditions. The Maintenance Director reported that vent cleaning was scheduled every three months and monitored through the TELS system, but admitted he had not noticed the dust accumulation during his daily rounds. No specific residents were identified as being directly affected at the time of the deficiency.
Failure to Notify Responsible Party and Dietician of Significant Change in Resident Condition
Penalty
Summary
The facility failed to notify the responsible party and the Registered Dietician (RD) of a significant change in a resident's condition, specifically regarding ongoing refusals of meals and medications. The resident, who had a history of hypertension, cognitive impairment, dysphagia, chronic kidney disease, and recent abnormal weight loss, began refusing meals and medications over several days. Documentation showed that the resident consumed less than 25% of meals or refused them entirely on multiple occasions, and also refused several doses of prescribed medications. Despite these changes, there was no documentation that the resident's representative or the RD were informed of the ongoing refusals and significant change in status. Staff interviews confirmed that the resident's behavior of refusing meals and medications was new and represented a significant change from previous patterns. The LPN stated that refusals were documented and the physician was notified, but the RD was not informed. The RD herself confirmed she was unaware of the refusals and would have reassessed the resident's nutritional plan had she been notified. The resident's representative also reported not being informed about the refusals and was unaware of the change in the resident's condition until contacted by surveyors. Facility policy required prompt notification of the resident, physician, and representative of significant changes in condition, including those requiring alterations in treatment. However, interviews with staff, including the MDS RN, Infection Preventionist/Unit Manager, DON, and Administrator, revealed inconsistent understanding and application of these policies. The lack of notification to the RD and responsible party was not documented, and staff acknowledged the importance of such communication but failed to ensure it occurred in this case.
Quarterly MDS Assessment Failed to Reflect Hospice Services
Penalty
Summary
The facility failed to accurately complete the Quarterly Minimum Data Set (MDS) assessment for one resident who was receiving hospice services. Review of the facility's policy on Maintaining Minimum Data Set (MDS) Assessments showed that it addressed record maintenance and retention but did not provide guidance to ensure accurate coding of services, such as hospice care, on Quarterly MDS assessments. The electronic medical record indicated that the resident was admitted to hospice services, but the corresponding Quarterly MDS assessment did not reflect this in section O, which covers Special Treatments, Procedures, and Programs. Staff interviews confirmed that hospice services were not coded on the assessment, and both the MDS RN and DON acknowledged the importance of accurate MDS coding for care planning.
Failure to Develop and Implement Comprehensive Care Plan for Oxygen Use
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for one resident with multiple respiratory diagnoses, including Alzheimer's Disease, COPD, respiratory failure, asthma, and heart failure. Despite the resident's Minimum Data Set (MDS) assessment indicating severe cognitive impairment and the need for oxygen therapy, the care plan did not include any problems or interventions related to respiratory conditions or oxygen use. Physician's orders documented the need for oxygen administration at 2 L/min via nasal cannula, weekly changes of oxygen tubing, weekly cleaning of the oxygen concentrator filter, and elevating the head of the bed for shortness of breath, but these were not reflected in the care plan. Observations confirmed that the resident was using oxygen as ordered, but interviews with the resident revealed uncertainty about the frequency of oxygen use. Staff interviews, including with the MDS RN and DON, confirmed that the care plan was missing required information regarding oxygen use and respiratory diagnoses. The MDS RN acknowledged that the omission was an oversight and emphasized the importance of accurate MDS coding for care planning. The DON also confirmed that the care plan should direct all aspects of resident care and must be accurate.
Failure to Prevent and Treat Pressure Ulcer in High-Risk Resident
Penalty
Summary
The facility failed to ensure that appropriate pressure ulcer prevention interventions were initiated, implemented, monitored, and documented for a resident identified as being at risk for pressure injuries, who developed a pressure ulcer during their stay. The facility's policy required comprehensive skin assessments upon admission and weekly for four weeks, as well as head-to-toe skin observations during showers and regular repositioning for bed-bound residents. However, documentation revealed that only limited skin assessments were completed during the resident's five-day respite stay, with no evidence of consistent monitoring or timely intervention when skin changes were noted. The resident in question was admitted for respite care with multiple complex medical conditions, including morbid obesity, acute respiratory failure, chronic heart failure, peripheral vascular disease, and severe cognitive impairment. The care plan indicated the resident was bed-bound, fully dependent for all activities of daily living, and required total assistance with bed mobility and self-care. Despite these risk factors, the electronic medical record showed that only two skin assessments were documented, and there was no evidence of regular repositioning or implementation of other pressure ulcer prevention measures as outlined in the facility's policy. When a pressure ulcer was identified on the resident's left heel, a physician's order for wound care was written, but there was no documentation that the treatment was provided or that the order was carried out. Interviews with staff confirmed that wounds should be reported and treated promptly, but no treatment notes or interventions were found in the record. Additionally, there was no documentation of care plan updates or evidence that staff addressed difficulties with repositioning the resident, despite reports of such challenges. This lack of assessment, intervention, and documentation contributed to the development and lack of treatment for the pressure ulcer.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
A deficiency was identified when a resident with a history of respiratory failure, hypoxia, pneumonia, and congestive heart failure was not administered oxygen therapy in accordance with the physician's orders. The resident's care plan specified continuous oxygen via nasal cannula at 2 liters per minute (LPM). However, multiple observations revealed that the oxygen concentrator was set below the prescribed 2 LPM, with flow rates recorded between 1.5 and 2 LPM. Staff interviews confirmed that the oxygen flow was not consistently set to the ordered rate, and the concentrator's marker was not properly aligned with the prescribed setting. Facility policy required nurses to initiate oxygen use as ordered, label tubing, and ensure orders for filter cleaning and humidification were entered into the system, as well as to check oxygen saturations as ordered by the physician. Despite these requirements, staff did not ensure the oxygen concentrator was set to the correct flow rate. Both the ADON and DON acknowledged that the oxygen was not set according to the physician's order and that nurses are responsible for monitoring and adjusting concentrators as needed.
Failure to Ensure Proper Administration of Corticosteroid Inhalers
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required by policy and manufacturer instructions. During 35 observed medication administration opportunities, two medication errors were identified, resulting in a 5.71% error rate. Specifically, during two separate medication passes, nursing staff did not instruct residents to rinse and spit after administering corticosteroid inhalers, despite clear facility policy and manufacturer instructions requiring this step. Both inhaler boxes had bright green notes stating, "Rinse mouth thoroughly after each use," but this directive was not followed during the observed administrations. Interviews with the involved LPNs revealed uncertainty and forgetfulness regarding the requirement to provide water and instruct residents to rinse and spit after inhaler use. The pharmacist confirmed that rinsing the mouth after using inhaled corticosteroids is necessary to prevent oral candidiasis and stated that staff were alerted to this requirement through labeling on the medication packaging. The DON and ADON also acknowledged that mouth rinsing is recommended for steroid inhalers and that staff were expected to encourage this practice, as indicated on the medication packaging.
Failure to Provide Required Feeding Adaptive Equipment at Meals
Penalty
Summary
Staff failed to provide a resident with the required feeding adaptive equipment at each meal, despite a physician's order and clear documentation on the resident's meal card indicating the need for built-up utensils. The resident, who had a history of stroke and significant difficulty eating without adaptive equipment, reported that the specialized utensils were usually missing from her meal tray. On multiple observed occasions, the resident's tray was delivered without the necessary adaptive device, and she had to request assistance from a CNA to obtain it, resulting in her food becoming cold before she could eat. Review of facility policy confirmed that residents should be assessed for adaptive equipment and provided with it as needed to facilitate independence. Interviews with the Dietary Manager and Administrator confirmed that there were sufficient devices available and that staff were expected to provide them when ordered by a physician. However, observations and interviews demonstrated that the process was not consistently followed, leading to the resident not receiving the required adaptive equipment at mealtimes.
Failure to Maintain Infection Control Practices and Policy Review
Penalty
Summary
The facility failed to maintain appropriate infection prevention and control practices as evidenced by multiple observed breaches and lack of policy review. During wound care, an LPN brought a full box of gloves into a resident's room, used gloves from the box, and then removed the same box for use with other residents, despite acknowledging that this practice could create a contamination risk. Additionally, a maintenance assistant exited a room under Contact Precautions for candida auris without wearing required PPE (gown or gloves) and did not perform hand hygiene after leaving the isolation room. The assistant also indicated a lack of knowledge regarding infection prevention protocols and had not received relevant training. Further review revealed that the facility's Infection Prevention and Control Program policy, last revised in October 2018, had not been reviewed or updated annually as required by the facility's own policy. Staff interviews confirmed that all personnel are expected to adhere to PPE and hand hygiene protocols, and that glove boxes used in resident rooms should not be removed to prevent cross-contamination. These failures were identified through observations, staff and resident interviews, and record review.
Inadequate Surety Bond Coverage for Resident Trust Funds
Penalty
Summary
The facility failed to maintain a Surety Bond in an adequate amount to cover the resident trust fund account balance for three of the six months reviewed. The Surety Bond was set at $80,000.00, which was insufficient to cover the ending balances of the resident trust fund account for February, May, and July 2024, which were $92,715.87, $93,849.05, and $95,520.15, respectively. This discrepancy was identified through a review of the facility's bank statements and the facility's policy titled 'Resident Trust Fund Accounting Policies and Procedures.' The Administrator confirmed the Surety Bond amount and the resident trust fund balances during an interview. She expressed uncertainty as to why the bond amount was not adjusted to exceed the highest monthly balance. The facility's Corporate Human Resources had based the bond amount on the resident trust fund balances from August 2021 to January 2022, as recommended by the bond company. This oversight had the potential to adversely affect the finances of 62 residents with trust fund accounts managed by the facility.
Deficiency in Dietary Manager Certification
Penalty
Summary
The facility failed to ensure that the staff designated as the Dietary Manager (DM) was certified in dietary or food service management, as required by their policy and CMS guidelines. The DM, who was promoted from a dietary cook position, did not possess any dietary certifications at the time of the survey. Although the DM was in the process of obtaining certification, she had not yet completed the necessary test. The facility policy required the DM to maintain current Serve Safe Food Handler certification and obtain Certified Dietary Manager (CDM) certification, which had not been fulfilled. The Administrator acknowledged that there was an expectation for the DM to at least obtain the Serve Safe Food Manager certification and eventually become a Certified Dietary Manager. However, the facility was not utilizing a DM from any sister facilities to assist with dietary oversight. The Registered Dietitian visited the facility once a month to provide dietary guidance, but the lack of a certified DM on staff at the time of the survey constituted a deficiency in meeting the required standards for food and nutrition services.
Deficiencies in Food Labeling, Storage, and Sanitization Procedures
Penalty
Summary
The facility failed to adhere to its policies regarding food labeling and storage, as well as proper sanitization procedures, leading to several deficiencies. In the dry storage area, an opened five-pound bag of grits was found without an open date, which was confirmed by the Dietary Manager (DM) as a failure to follow the facility's policy. In the walk-in freezer, an open case of frozen strawberries was observed with ice build-up on top, which the DM acknowledged was due to the air condenser's issues and confirmed that dietary staff had been removing the ice as needed. Additionally, in the resident nourishment room, several food items, including Styrofoam containers and frozen pizzas, were found without resident names or dates, which the DM and Administrator confirmed was the responsibility of the nursing staff, who had been previously educated on this requirement. Furthermore, the facility did not demonstrate proper sanitization procedures in the three-compartment sink. The dietary cook was observed submerging dish items in a quaternary sanitizing solution for only 20-30 seconds, contrary to the posted instructions that required at least one minute of immersion. The DM confirmed the discrepancy between the cook's practice and the posted guidelines, acknowledging that the dietary staff should have adhered to the one-minute immersion time as indicated by the posters above the sink.
Failure to Implement Stop Dates for Psychotropic Medications
Penalty
Summary
The facility failed to implement a stop date not exceeding 14 days for psychotropic medications for four residents, leading to a deficiency in medication management. The facility's policy requires that PRN orders for psychotropic drugs are limited to 14 days unless the prescribing practitioner documents a rationale for extending the order. However, the review of medical records revealed that residents were administered lorazepam and Ativan without a documented stop date, contrary to the facility's policy. Interviews with the Director of Nursing (DON) and Licensed Practical Nurse (LPN) Unit Managers indicated that the oversight occurred despite daily reviews of new medication orders. For instance, one resident had an order for lorazepam with an indefinite end date and was administered the medication multiple times over a month. Another resident had a similar order for lorazepam for agitation, also without a stop date, and was administered the medication on several occasions. The DON acknowledged the lack of stop dates and stated that the medication should have been reassessed before reordering. The facility's failure to adhere to its policy on psychotropic medication orders resulted in the deficiency identified by the surveyors.
Failure to Refer Resident for PASARR Level Two Review
Penalty
Summary
The facility failed to refer a resident for a preadmission screening and resident review (PASARR) level two, as required by their policy. The resident, identified as R33, was admitted with diagnoses including general anxiety disorder and major depressive disorder. Despite these diagnoses, the facility did not resubmit a PASARR for a level two review. The facility's policy mandates that any resident with a newly evident or possible serious mental disorder, intellectual disability, or related condition should be referred for a level two review. However, the Social Service Director did not believe a level two PASARR was necessary for R33, as the primary diagnosis was not considered a mental health diagnosis. Observations of R33 showed that she was cognitively intact, with no signs of depression or psychosis, and was receiving anti-anxiety and antidepressant medications. Interviews revealed that the facility was in the process of changing mental health service providers, and R33 was not currently receiving psychiatric services. The Administrator stated that the expectation was for the Social Service Director to review each resident's diagnosis and resubmit the PASARR for a level two review if a major mental health diagnosis was present. The failure to obtain a level two PASARR for R33 was identified as a deficiency, potentially placing the resident at risk for improper placement and inadequate mental health care.
Unattended Medication Cart Found Unlocked
Penalty
Summary
The facility failed to ensure that one of three medication carts was locked and secured when left unattended by a nurse, as observed during an initial tour. The medication cart was found unlocked and unattended in a hallway, with its drawers facing the hallway, making it easily accessible to residents, unauthorized staff, and visitors. A registered nurse (RN) responsible for the cart walked by it twice without securing it, and a resident was observed self-propelling past the cart. Upon being interviewed, the RN acknowledged the cart was unlocked and unattended but declined further comment. The facility's policy on medication storage requires that medication carts be locked or attended by authorized personnel. Interviews with the Administrator and the Director of Nursing (DON) confirmed that the expectation was for medication carts to be locked when unattended. The DON mentioned that a pharmacy consultant conducted random audits and provided monthly education to nursing staff, but there was uncertainty about whether night shift nurses received this education. The failure to lock the medication cart increased the risk of unauthorized access to medications.
Infection Control Breach During Resident Care
Penalty
Summary
The facility failed to adhere to proper infection control techniques while providing care to a resident on Enhanced Barrier Precautions (EBP). The facility's policy required staff to change the basin water, use a clean washcloth, perform hand hygiene, and don new gloves after washing and before rinsing the resident. Additionally, the policy specified that cleaning should begin at the face and work over the body, with the groin and buttocks cleaned last. However, during an observation, a Certified Nursing Assistant (CNA) did not follow these guidelines. The CNA used the same washcloth to clean the resident's catheter site, groin area, and entire front body, and used the same basin of water for washing and rinsing. Furthermore, the CNA did not don a gown while providing the resident with a bed bath, incontinent care, linen change, and dressing, despite the resident being on EBP due to an indwelling catheter. The CNA admitted to not wearing a gown and was unaware of the requirement to use PPE when caring for residents with Foley catheters, feeding tubes, PICC lines, or IVs. The CNA also stated she did not see the sign on the resident's door indicating EBP and had never read it. The Infection Control Preventionist (ICP) confirmed that staff were expected to wear gowns and gloves when providing care to residents on EBP and that all staff had received training on EBP. The ICP also stated that signs were posted on residents' rooms indicating the required PPE. Despite this, the CNA did not follow the proper procedures, leading to a potential risk of spreading infection within the facility.
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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