Colquitt Regional Senior Care & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Moultrie, Georgia.
- Location
- 101 Cobblestone Trace Se, Moultrie, Georgia 31768
- CMS Provider Number
- 115667
- Inspections on file
- 17
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Colquitt Regional Senior Care & Rehabilitation during CMS and state inspections, most recent first.
The facility failed to implement an effective Antibiotic Stewardship Program, leading to the prescription of antibiotics without proper diagnostic testing or symptom documentation. Over several months, multiple residents were prescribed antibiotics despite not meeting McGreer's criteria for infection. The Infection Preventionist and Director of Nursing confirmed the lack of interventions for these cases, and the facility's ASP data collection was inconsistent.
The facility failed to provide required transfer notices to three residents and their representatives before transferring them to the ER, as well as failed to notify the State LTC Ombudsman of these transfers. The transfer forms lacked information on appeal rights and Ombudsman contact details. The facility's administrator confirmed that prior to May 2024, transfer notices were not sent to the Ombudsman, and some transfers were omitted from the lists sent thereafter.
The facility failed to implement care plans for monitoring psychotropic medications for two residents. One resident was prescribed Aripiprazole and Escitalopram Oxalate without monitoring for side effects or behaviors, despite a care plan indicating such interventions. Another resident was prescribed Celexa, but monitoring for side effects and efficacy was not conducted until months later. The DON confirmed these oversights during interviews.
A facility failed to document discharge needs and assessment for a resident discharged home with a femur fracture. Despite being cognitively intact, there was no record of discharge needs or assessment in the progress notes. Discharge instructions lacked prior assessment documentation. Staff interviews revealed gaps in communication and documentation, with expectations for discharge documentation not being met.
A facility failed to document pressure ulcer dressing changes for a resident, leading to a lack of communication among staff. The facility's policy requires detailed documentation of treatments, but a review of the resident's progress notes showed only one entry over a two-month period. Interviews with the WN/RN and DON confirmed that documentation was inconsistent, despite instructions to record each dressing change.
A facility failed to document and collaborate effectively for a resident requiring dialysis care. The resident, with end-stage renal disease, had incomplete documentation on the Dialysis Transfer Form, missing vital signs, assessments, and signatures. Staff interviews confirmed these deficiencies, highlighting a lack of communication between the facility and the dialysis center.
The facility failed to accurately post daily nurse staffing information, as required by their policy, leading to outdated and incomplete data being displayed. The staffing document did not include certain CNAs, and the responsibility for posting was divided between the DON and RN Supervisor. This resulted in potential misinformation about the nursing staff available to care for the 54 residents.
Deficient Antibiotic Stewardship Program in LTC Facility
Penalty
Summary
The facility failed to develop an effective Antibiotic Stewardship Program (ASP) to monitor antibiotic use, as evidenced by the prescription and administration of antibiotics to residents without appropriate diagnostic testing or documented symptomology. The facility's policy on Antibiotic Stewardship, dated September 2022, required antibiotics to be prescribed and administered under the guidance of the ASP and Quality Assurance and Performance Improvement (QAPI) Committee. However, the facility's ASP data collection was inconsistent, with missing data for February 2024 and no interventions documented for residents whose symptoms did not meet McGreer's criteria for infection. Throughout the months from December 2023 to July 2024, multiple instances were noted where residents were prescribed antibiotics despite their symptoms not meeting McGreer's criteria. For example, in December 2023, three residents were prescribed antibiotics without meeting the criteria, and similar patterns were observed in subsequent months. The Infection Preventionist (IP) and Director of Nursing (DON) confirmed that there was no evidence of interventions for these cases, and the facility's ASP was not in place prior to December 2023. Interviews with the IP/DON revealed that the facility used McGreer's criteria to guide the ASP, but there was a lack of evidence for interventions or corrective actions for infections that did not meet the criteria. The IP/DON acknowledged the absence of ASP data for February 2024 and confirmed that no additional interventions were implemented beyond a June 2024 inservice on hand hygiene and perineal care. This deficiency in the ASP has the potential to affect all residents in the facility, with a census of 54 residents.
Failure to Provide Transfer Notices and Notify Ombudsman
Penalty
Summary
The facility failed to provide a written transfer or discharge notice with the required content to three residents and their representatives before transferring them to the emergency room. The facility's policy on transfer or discharge documentation mandates that appropriate notice be documented in the medical record when a resident is transferred. However, for three residents, there was no documentation in their electronic medical records indicating that they or their representatives were provided with the necessary transfer notice. These residents were transferred to the emergency room due to various medical conditions, including vomiting, abdominal pain, fever, and pneumonia, but the facility did not document the provision of transfer notices. Additionally, the facility did not notify the State LTC Ombudsman office of the transfers or discharges of these residents. The transfer forms provided to the residents' representatives lacked essential information, such as the residents' appeal rights and the contact details of the State Ombudsman office. The facility's administrator confirmed that prior to May 2024, the facility was not sending transfer notices to the State LTC Ombudsman. Although the facility began sending lists of transfers and discharges to the Ombudsman in May 2024, some transfers, including those of the residents in question, were not included in these lists.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to implement a care plan for monitoring the use of psychotropic medications for two residents, R154 and R31. For R154, the facility's policy on antipsychotic medication use was not followed, as there was no monitoring of side effects or behaviors related to the psychotropic medications prescribed, including Aripiprazole and Escitalopram Oxalate. Despite having a care plan that included interventions for mood issues, the Medication Administration Record (MAR) for August 2024 showed no evidence of monitoring for side effects or worsening behaviors. The Director of Nursing (DON) confirmed the lack of monitoring during an interview. Similarly, for R31, the facility did not monitor the side effects or efficacy of the antidepressant Celexa, which was prescribed to manage anxiety and depression. Although the care plan included monitoring for side effects and effectiveness, the MARs for May, June, and July 2024 showed no evidence of such monitoring. It was only on August 12, 2024, that monitoring was initiated. The DON acknowledged that the orders and MAR did not include monitoring conditions for Celexa, confirming the oversight during an interview.
Failure to Document Discharge Needs and Assessment
Penalty
Summary
The facility failed to document discharge needs and assessment for a resident, identified as R44, who was discharged home. R44 was admitted with a diagnosis of a fracture of the right femur and was cognitively intact with a BIMS score of 15 out of 15. However, there was no documentation in the progress notes regarding the discharge needs or assessment for R44, nor was there a record of the discharge date. The discharge instructions provided were dated and included information about medical equipment and a home health company, but lacked documentation of an assessment prior to discharge. Interviews with facility staff revealed gaps in the discharge process. The Social Services Director mentioned discussing equipment needs with R44's husband and faxing a referral to a home health agency, but there was no documentation confirming the agency received the referral. The LPN confirmed the absence of a discharge assessment in the progress notes. The DON and Administrator both expressed expectations for discharge documentation, including details about the resident's condition, medications, and equipment needs, which were not met in this case.
Failure to Document Pressure Ulcer Care
Penalty
Summary
The facility failed to document pressure ulcer dressing changes for a resident, identified as R49, which resulted in a lack of communication among staff involved in the resident's care. The facility's policy on Charting and Documentation requires detailed documentation of procedures and treatments, including the date and time, the name and title of the caregiver, assessment data, and the resident's response to treatment. However, a review of R49's progress notes from June 2024 to August 12, 2024, revealed only one entry on August 3, 2024, indicating that the wound was cleaned and bandaged per physician orders, with no further documentation of wound care. Interviews with the Wound Nurse/Registered Nurse (WN/RN) and the Director of Nursing (DON) confirmed that a progress note should be made each time a wound care dressing is performed, detailing the wound's appearance, drainage, odor, size, and improvement or deterioration. The WN/RN admitted to sometimes forgetting to document in both the Treatment Administration Record (TAR) and the progress notes. The DON stated that she had instructed the wound care nurse to make a progress note for each dressing change a couple of months prior, but this was not consistently followed, leading to the deficiency in documentation.
Incomplete Dialysis Documentation and Collaboration
Penalty
Summary
The facility failed to provide complete documentation and collaboration for a resident requiring dialysis care. The resident, identified as R9, was readmitted with diagnoses of end-stage renal disease and chronic kidney disease. The facility's policy and the dialysis contract required comprehensive documentation of dialysis services, including laboratory values, vital signs, medications, and any changes in the resident's medical status. However, the review of R9's Dialysis Transfer Form revealed incomplete documentation, with missing pre and post-dialysis assessments, signatures, dates, and times. The dialysis center also failed to complete sections of the form that were their responsibility. Interviews with staff, including an LPN and the DON, confirmed the deficiencies in documentation. The LPN acknowledged that the nurse should fill out vital signs and any changes in the resident's condition to inform the dialysis center. The DON confirmed that all areas of the pre and post-dialysis assessments should be completed by the nurse and that any missing documentation from the dialysis center should be addressed by contacting them and having the form completed. This lack of documentation and communication resulted in a deficiency in the care provided to R9.
Inaccurate Posting of Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the daily nurse staffing information was accurately posted to reflect the actual staff hours available to care for the 54 residents. The facility's policy required that the number of nursing personnel responsible for providing direct care to residents be posted daily for each shift within two hours of the beginning of each shift. However, an observation on 8/11/2024 revealed that the posted staffing information was outdated, showing the date of 8/9/2024 and indicating 52 residents instead of the current 54. This discrepancy was noted during a survey, and it was found that the document was not updated as required. Interviews with the Administrator revealed that the responsibility for posting the staffing information was assigned to the Director of Nursing (DON) during weekdays and the RN Supervisor on weekends. However, the daily nurse staffing document did not include certain CNAs, such as the rehabilitation CNA, the bath CNA, and the multipurpose CNA. The Administrator admitted that these CNAs were not included in the nursing schedule to prevent other CNAs from perceiving there were extra staff and potentially calling off. This omission led to inaccurate staffing information being posted, which could misinform residents, family members, or visitors about the available nursing staff.
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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