Crestview Health & Rehab Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Atlanta, Georgia.
- Location
- 2800 Springdale Road, Atlanta, Georgia 30315
- CMS Provider Number
- 115525
- Inspections on file
- 24
- Latest survey
- March 1, 2026
- Citations (last 12 mo.)
- 9 (3 serious)
Citation history
Health deficiencies cited at Crestview Health & Rehab Ctr during CMS and state inspections, most recent first.
Multiple residents with varying levels of cognitive impairment experienced sexual and physical abuse or inappropriate contact by other residents and by a CNA, including alleged sexual touching, an observed oral sex act, a resident slapping another resident, unwanted touching in a resident’s room, breast pinching, and a resident being forcibly moved and striking his head on a doorframe. Although some events were documented in progress notes and one resident was sent to the hospital, the facility did not complete thorough investigations, did not promptly perform or document physical and psychosocial assessments, and did not revise care plans or implement clear protective interventions and monitoring to prevent further abuse, contrary to its own abuse prevention policy.
The facility failed to conduct thorough investigations into multiple allegations of physical and sexual abuse involving several residents with cognitive impairment, psychiatric conditions, and complex medical histories. In numerous cases, police were notified and case numbers obtained, but there was no follow-up with law enforcement, no or limited interviews with other residents or staff who might have witnessed or known about the incidents, and no timely physical or psychosocial assessments of the involved residents. This pattern included resident-to-resident physical altercations, alleged sexual contact between residents, and an allegation that a CNA forcefully moved a resident, causing a head injury, as well as a complaint that an LPN attempted to force medication and struck a resident with a remote. The Manager of Quality/Risk and the Administrator acknowledged that investigations were incomplete and did not meet the facility’s own abuse policy requirements for identifying and interviewing all involved persons and thoroughly documenting investigations.
Administration failed to implement abuse policies and procedures and did not ensure thorough investigations after multiple residents reported physical and sexual abuse by staff and other residents. Incidents included a resident being grabbed and thrown against a doorframe by staff, resulting in a laceration, several residents reporting inappropriate touching or sexual abuse by other residents, and one resident slapping another in the face without provocation. The Administrator and DON acknowledged that the facility lacked policies and procedures to guide staff in identifying, reporting, investigating, and preventing abuse, despite the Administrator’s responsibility to assure care that promotes quality, safety, and respect.
Surveyors found that the facility did not properly obtain or document informed consent for psychotropic medications for three residents. One resident with dementia and behavioral disturbances was receiving Depakote ER for mood and agitation without any signed consent or documented risks vs benefits. A second cognitively intact resident with multiple psychiatric diagnoses was on four psychoactive medications (Klonopin, Abilify, Sertraline, Quetiapine); although a consent form was signed and witnessed due to the resident’s physical limitations, the form lacked required details such as specific drugs, dosages, frequencies, targeted behaviors, and potential side effects. A third severely cognitively impaired resident with dementia and other psychiatric conditions was receiving Valproate Sodium for behaviors without any signed consent or documented discussion of risks and benefits. The DON acknowledged that consents for these residents could not be located, despite a facility policy requiring such information and documentation before initiating or increasing psychotropic medications.
A resident with quadriplegia and idiopathic hypotension, who was cognitively intact, requested assistance in obtaining a Social Security card and a Georgia ID. Social services documented attempts to complete Social Security forms and discussed the issue with the resident’s out-of-state representative, who had health issues and relied on facility staff for help. An application for a Social Security card was completed, but there was no documented follow-up for more than three and a half months, and the resident never received the card or ID. During interviews, the resident and representative confirmed the documents were never obtained and described the situation as very stressful, while social services staff acknowledged that no follow-up occurred and that assisting with such matters was their responsibility under facility policy.
The facility did not ensure that residents were protected from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any person.
The facility failed to protect a resident from the wrongful use of their belongings or money, resulting in a deficiency related to safeguarding personal property and financial resources.
Surveyors found that a resident did not receive an accurate assessment, as required, due to incomplete or inaccurate documentation of their condition or needs.
A facility failed to provide required one-to-one supervision for four residents with severe cognitive impairments, as outlined in their care plans. This neglect was identified through observations and interviews, revealing that night shift CNAs were not informed of the supervision requirements and were assigned additional residents, compromising care. One resident was found on the floor and sent to the hospital, highlighting the facility's failure to adhere to its policy on abuse, neglect, and exploitation.
Failure to Protect Residents From Abuse and Implement Protective Interventions After Allegations
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from abuse and to implement adequate actions and care plan interventions after abuse allegations. One cognitively intact male resident with a history of verbal and sexual aggression toward staff was care planned for potential sexually abusive behavior, but his care plan and record contained no specific behavioral monitoring or interventions after two separate sexual abuse allegations by two cognitively intact female residents. One of these residents reported that he rubbed her inner thigh and hair in a way that made her feel violated, and documentation showed he was moved to another unit due to her allegation, yet there was no evidence of immediate physical or psychosocial assessment of her after the incident. The other resident reported being raped by this same male resident, was sent to the hospital, and refused examination, but her care plan did not show ongoing interventions to prevent further abuse by him. Another incident involved a male resident allegedly performing oral sex on his cognitively intact male roommate. A CNA discovered the roommate in bed with his penis exposed and the other resident bent over him, moving in an up‑and‑down motion. Progress notes documented that the social worker spoke with both residents three days later, but there was no evidence of an immediate physical assessment or timely psychosocial assessment of either resident to rule out physical or psychosocial harm. The care plans for both residents lacked any problem or interventions related to this sexual incident or measures to prevent further sexual abuse. Observations later showed the alleged perpetrator alone in a private room, rarely leaving his room and requiring extensive assistance, but there was no documentation of specific monitoring or protections related to the prior allegation. The facility also failed to adequately address physical abuse and inappropriate contact among other residents and by staff. One severely cognitively impaired resident with known behavioral issues had previously been placed on 1:1 care after attempting to hit staff and then hitting another resident, yet her care plan did not address a later incident in which she slapped another cognitively impaired resident in the face when redirected from striking staff. Although a progress note documented that no injuries were noted and the situation was de‑escalated, the investigation file was incomplete. In separate cases, a moderately impaired resident reported through a family member that another severely impaired resident entered her room and touched her body, and a cognitively intact resident was observed being pinched on the breast by another cognitively impaired resident, causing her to yell out. The investigative files confirmed these reports but did not show that care plans were updated or that protective measures were implemented. In addition, a severely cognitively impaired resident with Alzheimer’s disease sustained a head laceration when a CNA, while providing personal care with another aide present, grabbed the resident by the sweater, jerked him from a seated position, and swung him toward the bathroom after he refused care, causing his head to hit the doorframe. A nurse entered the room and witnessed the CNA swinging the resident and the impact with the doorframe. The facility’s Manager of Quality/Risk Manager, who conducted most abuse investigations, confirmed that the facility’s investigative materials for all of these incidents were incomplete and that abuse was substantiated only in the case of the physical abuse by one resident against another. She and the Administrator acknowledged there was no documentation of prompt resident assessments, care plan updates, or adequate measures to prevent further abuse by the involved residents and the CNA, despite facility policies requiring immediate protection, examination, psychosocial assessment, room or staffing changes, emotional support, and care plan revision after incidents of abuse.
Failure to Conduct Thorough Abuse Investigations
Penalty
Summary
The deficiency involves the facility’s failure to conduct thorough investigations into multiple allegations of abuse, including physical and sexual abuse, involving numerous residents. For several incidents, the facility notified local law enforcement and obtained case numbers but did not follow up with the police department to obtain information about their investigations. In the cases involving a resident with a history of stroke who alleged being punched by another resident, later alleged sexual touching by a male resident, and was involved in a separate altercation with another resident who threw items at her, the facility’s investigative files lacked follow-up with police, interviews with other residents who may have witnessed or had knowledge of the events, and timely physical and psychosocial assessments of the involved residents. Similar investigative gaps were identified in an incident where a resident with an above-knee amputation was alleged to have hit another resident. The facility also failed to complete thorough investigations into serious allegations of sexual abuse between residents with significant psychiatric and cognitive diagnoses. In one incident, a CNA reported finding one resident bent over another resident’s bed with his penis in the other resident’s mouth; both residents had diagnoses including paranoid schizophrenia and vascular dementia. Although police were notified and a case number was obtained, the facility did not follow up with law enforcement, did not interview other residents who may have been exposed to or had knowledge of the incident, and did not complete timely physical or psychosocial assessments of either resident. In another case, a cognitively impaired resident reported being touched on the thigh by another resident with severe cognitive impairment while in bed; both residents later denied or could not recall the event, and the facility did not obtain statements from other potentially affected residents or staff who may have been present, determining the allegation unsubstantiated based solely on the residents’ lack of recall. Additional deficiencies in abuse investigations were identified in incidents of resident-to-resident physical abuse and alleged staff-to-resident abuse. In one case, a cognitively intact resident reported that another resident with dementia pinched her breast; while the facility determined that abuse occurred and documented some interviews, it did not obtain statements from other residents potentially affected or staff who may have been present. In another incident, a resident with Alzheimer’s disease and severe cognitive impairment sustained a head laceration when a nurse aide allegedly grabbed the resident by the sweater and shirt, jerked the resident from a seated position, and swung the resident toward the bathroom, causing the resident’s head to hit the doorframe; despite witness statements from another aide and an LPN, the facility ultimately determined it could not verify abuse after the resident later denied being abused. In a separate complaint from a resident with severe cognitive impairment and significant behavioral disturbances, who alleged that an LPN tried to force a pill down his throat and hit him with a TV remote, the facility’s investigation included multiple documents and interviews but did not include interviews of other residents cared for by the implicated LPN. The pattern of incomplete investigations extended to additional resident-to-resident physical abuse incidents. In one event, a resident with vascular dementia and a history of breast cancer attempted to hit a nurse and then slapped another resident with dementia and diabetes in the face; the facility notified responsible parties and updated care plans but did not document interviews with other residents in the area or psychosocial assessments of the involved residents, despite notifying police and receiving a case number. Across these events, the Manager of Quality/Risk Manager, who conducted most of the abuse investigations, confirmed that investigation information was never obtained from the local police department, that timely physical and psychosocial assessments were not completed, and that residents who may have been present or had knowledge of the incidents were not interviewed. The Administrator, who served as the Abuse Coordinator and reviewed investigations, acknowledged that the referenced investigations were not complete, even though facility policy required identifying and interviewing all involved persons and others who might have knowledge of the allegations, and providing complete and thorough documentation of the investigation.
Failure to Implement Abuse Policies and Investigate Multiple Abuse Allegations
Penalty
Summary
Facility administration failed to implement its abuse policies and procedures for 15 of 25 sampled residents, resulting in noncompliance that surveyors determined had caused or had the likelihood to cause serious injury, harm, impairment, or death. The Administrator did not ensure residents remained free from neglect and abuse after multiple allegations of physical, sexual, and other forms of abuse were made by and between residents and staff. Specific incidents included a resident alleging that a staff member grabbed him by the shirt and threw him against a doorframe, causing a laceration above his eye, and several residents reporting that other residents touched them inappropriately in their private areas or engaged in sexual abuse. Another incident involved a resident slapping another resident in the face without provocation. In each of these situations, the administration failed to ensure adequate actions were taken to prevent further potential abuse by staff or residents. The Administrator also failed to ensure thorough investigations of abuse allegations for 14 residents reviewed for abuse. Despite multiple reports and observations of alleged abuse, including sexual abuse between residents, physical abuse by staff toward a resident, and physical abuse between residents, the facility did not conduct comprehensive investigations as required. During an interview, the Administrator and DON confirmed that the facility lacked policies and procedures directing staff on how to identify, report, investigate, and prevent resident abuse, despite the Administrator’s job description assigning responsibility for assuring that care promotes quality, safety, and respect. Surveyors identified Immediate Jeopardy beginning when one resident alleged that another resident sexually abused her by touching her between her legs, and found that the facility’s failure to implement its Abuse Policy placed all residents at risk of unreported and uninvestigated abuse.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency in the facility’s management of psychotropic medications related to informed consent and documentation of risks and benefits for three residents. For one resident with dementia with behavioral disturbances and adjustment disorder, the EMR showed an order for Depakote ER 250 mg at bedtime for mood stabilization and episodic agitation, but there was no signed consent or documentation of risks versus benefits for psychoactive medications in the resident’s miscellaneous documents. Another resident with schizoaffective disorder, bipolar type, bipolar disorder, adjustment disorder with mixed anxiety and depression, and psychosis had intact cognition and was receiving multiple psychoactive medications, including Klonopin, Abilify, Sertraline, and Quetiapine. The consent form for psychoactive medication for this resident was signed and witnessed by facility social workers because the resident had no hands or arms and verbally gave permission, but the form did not list any of the required medication details such as drug name, dosage, frequency, targeted behavior, or potential side effects for any of the four medications. A third resident with dementia with behavioral disturbances, personality disorder, major depressive disorder, and psychosis, and who was severely cognitively impaired with a BIMS score of 0, had a physician order for Valproate Sodium oral solution 250 mg/5 ml, 2.5 ml twice daily for behaviors. Review of this resident’s miscellaneous documents also showed no signed consent or documentation of risks versus benefits for psychoactive medications. During an interview, the DON confirmed she was unable to locate signed psychoactive medication consents for these three residents. The facility’s own policy on the use of psychotropic medications, revised in May 2025, requires that prior to initiating or increasing psychotropic medications, the resident, family, and/or representative be informed of benefits, risks, alternatives, and any black box warnings, and that this information be documented in a format such as a written consent form or narrative note, which was not done in these cases.
Failure to Provide Social Services Assistance for Resident Identification Documents
Penalty
Summary
The facility failed to provide medically-related social services to assist a cognitively intact resident in obtaining a Social Security card and state identification, as required by facility policy. The resident, who had quadriplegia and idiopathic hypotension, was admitted to the facility and had a BIMS score of 15/15, indicating intact cognition. Care planning notes documented that during an interdisciplinary care plan meeting with the resident’s mother/representative, the SW informed her that another attempt had been made to complete the Social Security form so the resident could receive a Social Security card, with the resident’s stated end goal being to obtain a Georgia ID. At a subsequent care plan meeting, the SW discussed with the mother whether she could assist with getting the Social Security card after two unsuccessful attempts, and it was noted there were no psychosocial concerns at that time. An application for a Social Security card was completed for the resident on 11/10/2025, but a review of the comprehensive record showed no documentation of any follow-up by the facility after that date regarding the Social Security card or Georgia ID. In an interview, the resident confirmed he had never received his Social Security card or Georgia ID and stated he would like to obtain those items. The resident’s mother/representative confirmed the card had never been received, reported that the situation had been very stressful for both of them, and stated she lived out of state with her own health problems and was relying on facility staff for assistance. During interviews, the SW and SSD confirmed there had been no follow-up by the facility since 11/10/2025, a period of more than three and a half months, and acknowledged that social services staff were responsible for assisting with such matters. The facility’s Social Services Policy stated that the facility would provide medically-related social services to assist each resident in attaining or maintaining their highest practicable well-being, including making arrangements for obtaining personal items and making referrals to outside entities.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure a safe and abuse-free environment for all individuals in their care.
Failure to Protect Residents' Belongings or Money
Penalty
Summary
A deficiency was identified regarding the protection of residents from the wrongful use of their belongings or money. The report documents that the facility failed to ensure that each resident was safeguarded against unauthorized or improper use of their personal property or financial resources. Specific details about the actions or inactions that led to this deficiency, as well as information about the residents involved or their medical history, are not provided in the report excerpt.
Failure to Ensure Accurate Resident Assessment
Penalty
Summary
A deficiency was identified regarding the facility's failure to ensure that each resident received an accurate assessment. The report notes that the required assessment process was not properly completed for one or more residents, resulting in inaccurate or incomplete information being documented about their condition or needs. This lapse in the assessment process was observed by surveyors during their review of resident records and facility practices.
Neglect Due to Inadequate Supervision in LTC Facility
Penalty
Summary
The facility failed to protect the rights of four residents from neglect, as they did not receive the required one-to-one supervision and monitoring as outlined in their care plans. This deficiency was identified through observations, staff interviews, and record reviews. Specifically, one resident was found on the floor and sent to the hospital for evaluation, although they were discharged without injury. The care plans for these residents indicated severe cognitive impairments and required constant supervision, which was not provided during the night shifts. The facility's policy on abuse, neglect, and exploitation mandates increased supervision for residents requiring one-on-one care. However, the review of CNA assignments from April to July 2024 revealed that the necessary supervision was not implemented during night shifts. Interviews with the Assistant Director of Nursing and the Administrator revealed a lack of awareness regarding the failure to follow care plans and physician orders for one-on-one supervision. The night shift CNA was assigned additional residents, which compromised the ability to provide the required supervision. The investigation into the incident revealed that the CNA assigned to the resident requiring one-on-one supervision was unaware of this requirement and was tasked with caring for 14 additional residents. The facility's failure to ensure that staff were informed and compliant with care plan interventions led to the neglect of the residents' needs. The facility's actions, including the suspension and termination of involved staff, were not part of the deficiency but were noted during the investigation.
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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