Comfort Creek Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wadley, Georgia.
- Location
- 10200 U.s. Hwy 1 South, Wadley, Georgia 30477
- CMS Provider Number
- 115679
- Inspections on file
- 20
- Latest survey
- April 21, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Comfort Creek Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and traumatic brain injury was found unresponsive and CPR was initiated. Despite facility policy requiring prompt notification, the family and physician were not informed of the change in condition or emergency interventions until after the resident was pronounced deceased. Staff interviews confirmed the delay in notification, and the family expressed distress over not being notified sooner.
Two residents with behavioral health diagnoses and a history of aggression engaged in a verbal and physical altercation, resulting in a minor injury. Despite care plans identifying aggression risks and facility policy requiring monitoring of provoking behaviors, staff did not prevent the incident, leading to a failure to protect residents from abuse.
A resident with moderate cognitive impairment and multiple psychiatric diagnoses was not invited to participate in their care conference, contrary to facility policy. Documentation showed only the resident's sister was included, and interviews with the resident and staff confirmed the resident was not invited or aware of the meeting.
A resident with a tracheostomy, who was care planned to perform self-care with staff observation and supply support, did not receive appropriate supervision or necessary supplies for tracheostomy care. The resident used non-sterile items like toilet paper and napkins due to lack of supplies, and staff did not directly observe or assist with care, instead relying on the resident's verbal confirmation. Nursing staff were unaware of the correct tracheostomy tube size and could not promptly locate supplies, resulting in the resident not receiving tracheostomy care as ordered.
A resident with a full code status was found unresponsive, and the facility failed to call 911 and continue CPR as required. Despite staff efforts to perform CPR, there was no documentation of EMS being contacted, and the Medical Director ordered CPR to stop after 20 minutes. The facility lacked an AED and proper hands-on CPR training, contributing to the deficiency.
A facility failed to follow proper CPR procedures for a resident with a resuscitation order, as staff did not contact EMS during the process. The incident involved an LPN who initiated CPR with other staff but did not document EMS notification, a critical step in the emergency response. The DON confirmed the oversight, and the Administrator was unsure of the CPR policy and AED availability.
Failure to Promptly Notify Family and Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to provide timely notification to a resident's family and physician following a significant change in the resident's condition. According to the facility's policy, when a resident experiences a change in condition, the physician and family or responsible party must be notified promptly. In this case, a resident with a diagnosis of diffuse traumatic brain injury, who was bedbound, non-communicative, and had severe cognitive impairment, was found unresponsive and not breathing late at night. CPR was initiated, and emergency medical services (EMS) were called. Despite these critical events, the family and physician were not notified immediately. Documentation and staff interviews revealed that after the resident was found unresponsive and CPR was started, multiple attempts were made to contact the Medical Director and Director of Nursing, but there was no immediate response. The resident was not pronounced deceased until several hours later, and only then was the family notified. Staff confirmed that the family was not informed of the change in condition or the initiation of CPR until after the resident was officially pronounced deceased. The facility's policy required prompt notification, but this was not followed. The family member interviewed expressed distress and confusion about not being informed sooner, learning of the resident's death only hours after the event. Staff interviews further confirmed that the family was not notified during the critical period when the resident was unresponsive and resuscitation efforts were underway. The delay in notification was attributed by staff to the fact that the resident had not yet been pronounced deceased, despite the clear change in condition and initiation of emergency interventions.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse by other residents, as evidenced by an altercation between two residents with known behavioral issues. One resident, with a history of major depressive disorder, psychotic disorder, dementia, bipolar disorder, PTSD, paranoid schizophrenia, and anxiety disorder, was identified as having moderate cognitive impairment and a care plan noting behavior problems related to physical aggression. The other resident, diagnosed with muscle weakness and major depressive disorder, was cognitively intact. Both residents were documented as being both givers and receivers of physical aggression in their care plans. On the day of the incident, a verbal altercation escalated when one resident was waiting for the other to retrieve items from a breakfast cart. After an exchange of words, one resident struck the other, who then followed him to his room and threw water on him, leading to a physical fight. The incident resulted in a minor injury, specifically a skin tear on one resident's hand. Staff interviews confirmed that the altercation was provoked by verbal exchanges and that both residents had a history of aggressive interactions. The facility's policy required staff to monitor behaviors that could provoke reactions and to review resident-to-resident abuse as potential abuse situations. Despite being aware of one resident's history of altercations at another facility and the behavioral risks identified in both residents' care plans, the facility did not implement sufficient measures to prevent the altercation. The failure to adequately monitor and intervene placed residents at continued risk of harm.
Resident Not Invited to Care Conference
Penalty
Summary
The facility failed to ensure that a resident participated in their care conference, as required by facility policy and regulatory standards. According to the facility's RAI/Care Planning Management document, residents are to be personally invited to care conferences by the social services department on the morning of the meeting, and invitations are mailed to family or responsible parties one week prior. Record review for a resident with multiple psychiatric and cognitive diagnoses, including moderate cognitive impairment, showed that while the resident's sister was included in the baseline care plan meeting, there was no documentation that the resident was invited to participate. During interviews, the resident confirmed not being invited to a care plan meeting and was unaware of what a care plan meeting was. The DON stated that only the responsible party was invited and was unsure if residents were included, while the Administrator affirmed that residents should be invited and that meetings could be held in residents' rooms if needed. The lack of resident invitation to the care conference was confirmed through both documentation and interviews.
Failure to Provide Tracheostomy Care, Supervision, and Supplies
Penalty
Summary
A resident with a history of cervical disc disorder and traumatic amputation was admitted to the facility with a tracheostomy and was care planned to perform self-care of his tracheostomy site, with staff instructed to observe and ensure supplies were available. The resident was cognitively intact and had physician orders for daily and as-needed tracheostomy care, including changing the inner cannula, performing trach care every shift, suctioning as needed, and changing the tracheostomy tie weekly. Despite these orders and care plan instructions, the resident reported that staff did not check on him during tracheostomy care, and there were no tracheostomy care supplies or suction equipment available in his room as required. During interviews and observations, the resident stated he used non-sterile items such as toilet paper and napkins to clean and support his tracheostomy tube due to a lack of appropriate supplies. He also revealed that his inner cannula had not been changed or cleaned since admission, and possibly for over a year, and that he would clear blockages himself by removing the inner cannula and coughing out mucus. Staff interviews confirmed that nursing staff had not observed or performed tracheostomy care for the resident, and documentation of care was based on the resident's verbal confirmation rather than direct observation or assistance. Further investigation revealed that staff were unaware of the resident's tracheostomy tube size and were unable to promptly locate appropriate supplies in the supply room. The facility was undergoing a transition with no designated treatment nurse, and regular nursing staff were responsible for treatments. Despite care plan instructions and physician orders, there was a lack of supervision, observation, and provision of necessary supplies for the resident's tracheostomy care, resulting in the resident using inadequate materials and not receiving proper care as ordered.
Failure to Activate 911 and Continue CPR
Penalty
Summary
The facility failed to activate 911 and continue CPR for a resident who was found unresponsive and without vital signs. The resident, who had a diagnosis of chronic obstructive pulmonary disease with acute exacerbation, was admitted with a physician's order to attempt resuscitation in the event of no pulse and no breathing. Despite this, the facility staff did not call 911, and CPR was stopped following an order from the Medical Director after approximately 20 minutes of resuscitation efforts. Interviews with the staff involved revealed a lack of clarity and communication regarding the emergency response procedures. LPN AA, who initially found the resident unresponsive, did not ensure that 911 was called, assuming that RN CC had made the call. However, RN CC confirmed that she did not call EMS, and there was no documentation to indicate that EMS was contacted. The facility's policy required that CPR be continued until EMS arrived, but this was not adhered to, leading to the resident's death. Further interviews with the Director of Nursing and other staff members highlighted a lack of proper equipment and training. The facility did not have an AED or defibrillator, and the CPR training provided to staff was online without hands-on practice. This deficiency in emergency preparedness and response contributed to the failure to provide adequate life-saving measures for the resident.
Removal Plan
- Licensed Nurses LPN AA and RN CC failed to continue Cardiopulmonary resuscitation until 911 services were called on R1.
- Licensed Nurse LPN AA and RN CC received CPR certification to include continuing CPR until 911 services arrive.
- Senior President of Clinical Services reviewed the policy Emergency Response Management policies and procedures and concluded no revisions were made.
- The Medical Director was educated on the policy and procedure for the Emergency Response Management by the Administrator.
- The Regional Nurse Consultant educated Director of Nursing and Administrator on Emergency Response Management policy and procedure.
- Education for the Emergency Response Management policy and procedure was completed by Director of Nursing and/or licensed staff. 3 of 4 RNs, 16 of 17 LPNs, 40 of 44 CNAs, 9 of 9 Dietary Staff, 9 of 14 Therapy staff, 3 of 3 Maintenance Director, 1 of 1 Business office Manager, 1 of 1 Social Service Director, 1 of 1 Activities Director, 1 of 1 Director of Nursing, 1 of 1 Administrator, 7 of 11 Housekeeping, 1 of 1 Admission Director, and 1 of 1 Human Resource Director 86.20 % of education was completed for all staff.
- All staff not educated on Emergency Response Management will be in-serviced prior to working their next scheduled shift by the Administrator, Director of Nursing, and or Licensed Nurse. All new hires will be educated during their onboarding process.
- An Advance Directive audit was completed by the Social Service Director to include the Physician Orders for Life-Sustaining Treatment (POLST), physician order, and care plan is accurate. 58 Residents elected to receive Cardiopulmonary resuscitation, and 21 residents elected to be a Do Not Resuscitate status for a total of 79, with one resident currently in the hospital. The Administrator and/or Director of Nursing will update daily the Advance Directive Audit tool and the Event Monitoring tool (to include residents who receive CPR) including weekends and holidays.
- 10 of 10 licensed staff received Cardiopulmonary Resuscitation Certification provider whose training includes hands-on practice and in person skills assessment. The additional 11 licensed nurses had CPR Certification prior to compliance date. The total of licensed nurses with CPR certification is 100%.
- The Regional Nurse Consultant and or Regional MDS Nurse reviewed 79 of 79 resident's records of the Advance Directive audit to ensure orders, POLST, and care plans are completed accurately in the resident record.
- The Administrator conducted an Ad Hoc QAPI (Quality Assurance Performance Improvement) meeting which consists of the Medical Director, Regional President of Operations, Business Office Manager, Social Service Director, MOS nurse, Certified Nurse Assistant, and licensed nurse to review the results of the most recent survey outcomes. The IDT (interdisciplinary Team) will review daily during morning clinical meeting to ensure compliance with following the Clinical Emergency Response Policy to include notifying 911 during CPR, auditing Advance Directives, Physician orders, and Care Plans.
Failure to Notify EMS During CPR
Penalty
Summary
The facility failed to ensure that staff followed appropriate procedures when providing Cardiopulmonary Resuscitation (CPR) for a resident who was reviewed for code status. The deficiency was identified when a resident, who had a physician's order to attempt resuscitation, was found unresponsive and without vital signs. The staff initiated CPR but failed to contact Emergency Medical Services (EMS) as required by the facility's Clinical Emergency Response Policy. The incident involved a Licensed Practical Nurse (LPN) who, upon finding the resident unresponsive, paged a code and returned with additional nursing staff to initiate CPR. Despite the ongoing resuscitation efforts, there was no documentation that EMS was contacted, which is a critical component of the emergency response protocol. The Director of Nursing (DON) confirmed that there was no documentation of EMS being called, and the Administrator was unsure of the facility's CPR policy and whether an Automated External Defibrillator (AED) was available. The failure to notify EMS during the CPR process was a significant oversight in the facility's emergency response procedures. This noncompliance with the established protocol had the potential to cause serious harm to the resident, as timely EMS intervention is crucial in such situations. The deficiency highlighted a lack of effective oversight and monitoring of facility procedures related to residents requiring CPR.
Removal Plan
- The administration failed to notify emergency management while providing Cardiopulmonary Resuscitation. The licensed nurse failed to notify 911 during CPR. It was identified the facility failed to implement all components of the Clinical Emergency Response Policy that included notifying 911 during CPR.
- The Administrator and DON were re-educated by the Regional President of Operation on Clinical Emergency Response Policy.
- The Regional Nurse Consultant re-educated the Administrator and DON on the job description.
- The Administrator will have daily calls with the Regional President of Operations regarding process of the plan, identified concerns and non-compliance identified items. The Administrator and/or DON will update daily the Advance Directive Audit tool and the Event Monitoring tool (to include residents who receive CPR) including weekends and holidays.
- The Regional Nurse Consultant and Regional President of Operations will visit the facility daily to ensure compliance and identify any areas of concern with not notifying emergency management (911) during CPR. A review of the findings will be placed in a weekly trip report by the Regional Nurse Consultant and Regional President of Operations.
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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