Crossings At East Lake Of Journey Llc, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Decatur, Georgia.
- Location
- 304 Fifth Avenue, Decatur, Georgia 30030
- CMS Provider Number
- 115482
- Inspections on file
- 23
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Crossings At East Lake Of Journey Llc, The during CMS and state inspections, most recent first.
The facility failed to implement an effective infection prevention and control program, including Enhanced Barrier Precautions (EBP). A CNA provided hygiene care and a brief change to a resident with multiple wounds and a feeding tube without donning a gown, despite posted EBP signage and available PPE, stating she did not believe EBP was required. The IP could not provide evidence of ongoing infection surveillance audits beyond a few peri care/hand washing audits from a single month and was unaware that routine surveillance auditing was required. The DON reported that only informal walk‑throughs occurred, with no formal, documented infection control audits, and could not produce any CNA infection control competency checkoffs for practices such as hand hygiene and PPE use, contrary to facility policies requiring surveillance, staff training, and demonstrated competency.
A resident who required mechanical lift transfers with two staff, as documented in their care plan, was transferred by a CNA without the lift or a second staff member, resulting in the resident sliding to the floor. The resident was not injured and attributed the incident to wearing socks. Review of records and staff interviews confirmed the care plan was not followed at the time of the event.
Staff did not follow the RD's order for continuous tube feeding for a resident with severe dysphagia and cognitive impairment, instead holding the feeding for four hours daily without a current order to do so. This practice was confirmed by staff interviews and observation, despite the current order specifying continuous feeding with only a one-hour stop for residual checks.
Two residents with severe cognitive impairment and feeding tubes did not receive care under Enhanced Barrier Precautions as required by their care plans. Staff provided care without using appropriate PPE or posting necessary signage, and some staff were unaware of the EBP requirements.
The facility failed to maintain an effective pest control program, resulting in a roach infestation in several resident rooms. Observations and resident interviews confirmed the presence of roaches, with pest sighting logs documenting numerous reports. Pest control technician reports highlighted sanitation issues, noting that areas such as nurses' desks and resident dresser drawers were not adequately cleaned, contributing to the persistence of the problem.
The facility failed to ensure call lights were accessible for two residents, leading to potential delays in assistance. One resident with aphasia and muscle weakness had the call light on the floor, while another with Parkinson's and contractures was unable to reach the call light due to its improper placement. Staff interviews confirmed the call lights should have been accessible, but inconsistencies in staff understanding and a lack of policy contributed to the deficiency.
A resident with a history of cerebrovascular accident and other medical conditions was not assisted back to bed for a nap despite expressing the desire to do so. The CNA preferred to wait until after lunch to avoid multiple transfers, which contradicted the resident's right to make personal choices as outlined in the facility's guidelines. Interviews with staff confirmed the resident's right to decide when to lie down was not honored.
A facility failed to accurately code a fall with major injury on the MDS for a resident who had a history of fractures. The resident sustained a fall while attempting to get out of bed without assistance, resulting in a proximal fracture to the left tibia, which required hospitalization. The fall was not documented in the quarterly MDS assessments, as confirmed by the MDS Coordinator.
A facility failed to revise a care plan for a resident with a history of CVA and contractures, as it did not address refusals of restorative care, including splint use, nor document alternative interventions. Observations showed the resident not wearing prescribed splints, and staff interviews confirmed the lack of documentation of refusals in the care plan prior to the survey.
The facility failed to provide adequate ADL care for three residents, resulting in deficiencies in personal hygiene and grooming. A resident with diabetes and vision impairment had long, dirty fingernails causing discomfort, while another with Parkinson's disease had unkempt nails despite expressing discomfort. A third resident did not receive regular showers, leading to dry, scaly skin. Staff interviews revealed inconsistencies in care and documentation, contributing to unmet hygiene needs.
A facility failed to provide consistent restorative services for a resident with moderate cognitive impairment who required substantial assistance with daily activities. Despite physician orders for splints to increase range of motion and prevent contractures, there was no documentation of the resident receiving these services. Observations confirmed the resident was not wearing the prescribed splints, and staff interviews revealed a lack of awareness or documentation regarding the resident's restorative care needs. The Director of Nursing acknowledged the oversight but could not provide documentation due to system issues.
The facility failed to lock medication carts on the 100-Hall and 200-Hall during administration, leaving them unattended and accessible. Additionally, expired medications were found in carts on the 100-Hall and 500-Hall, including iron tablets and aspirin. Staff interviews confirmed these practices violated facility policies, potentially leading to medication errors and adverse resident outcomes.
A facility failed to document restorative nursing services for a resident with a history of CVA and contractures, as required by their policy. Despite physician orders and therapy recommendations for passive ROM exercises and splint application, no documentation was found in the resident's medical records. Interviews with staff confirmed the absence of records, citing system acquisition issues during a transition from previous ownership as a contributing factor.
A facility failed to adhere to its hand hygiene policy during wound care for a resident with a stage 4 pressure ulcer. The Wound Care Nurse did not sanitize her hands between glove changes, contrary to the facility's guidelines. The resident, who had intact cognition, was at risk of infection due to this oversight. Interviews with the Unit Manager and DON confirmed the breach in protocol.
Failure to Implement Effective Infection Prevention and Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program as required by its own policies. The facility’s Infection Prevention and Control Program policy required a system of surveillance for prevention, identification, reporting, investigation, and control of infections for residents, staff, volunteers, visitors, and others, with the Infection Preventionist (IP) responsible for leading surveillance activities, maintaining documentation, and reporting findings to the Quality Assessment and Assurance Committee. The policy also required that all staff receive training on the infection prevention and control program and demonstrate competence in relevant infection control practices. The Infection Preventionist policy required development and implementation of an ongoing infection prevention and control program and oversight of resident care activities. The Enhanced Barrier Precautions (EBP) policy required staff training on EBP, high‑risk activities, and organisms requiring EBP; obtaining EBP orders for residents with wounds and/or indwelling medical devices such as feeding tubes; making gowns and gloves available outside resident rooms; and periodic monitoring of adherence. Despite these policies, the IP was unable to provide documentation of ongoing infection surveillance audits or staff competency validations for the previous 12 months, producing only nine peri care/hand washing audit tools from a single month and stating she had not been auditing staff or was aware that routine surveillance auditing was required. The DON similarly reported that no formal infection control audits were conducted and could not produce any CNA infection control competency checkoffs. In addition to the lack of surveillance and competency documentation, staff failed to follow EBP requirements during direct resident care. A CNA provided hygiene care, including a brief change, to a resident who had multiple wounds and was receiving tube feeding, conditions that met the facility’s criteria for EBP, without donning a gown despite posted signage on the resident’s door and PPE available outside the room. The CNA confirmed she did not wear the required gown and stated she believed the resident did not have a condition requiring EBP precautions. The IP later stated she expected staff to wear PPE when providing direct contact with a resident on EBP, and the DON stated his expectation was that staff follow established protocols and use PPE as required, but acknowledged that leadership only conducted informal walk‑throughs without formal, documented infection control audits. These observations, interviews, and record reviews showed failures in consistent PPE use under EBP, failure to conduct required infection surveillance audits, and absence of documented staff infection control competency validation.
Failure to Follow Care Plan for Mechanical Lift Transfer
Penalty
Summary
The facility failed to implement the care plan for a resident requiring mechanical lift transfers with assistance from two staff members. According to the resident's care plan, mechanical lift transfers with two staff were required for all transfers. However, during a transfer from wheelchair to bed, a certified nurse aide (CNA) did not use the mechanical lift or a second staff member, resulting in the resident sliding to the floor. The resident attributed the incident to wearing socks and reported no pain or injury, denying hitting their head. Review of facility records and staff interviews confirmed that the care plan intervention for mechanical lift with two staff was in place at the time of admission and not followed during the incident.
Failure to Follow Tube Feeding Orders for Resident with Severe Dysphagia
Penalty
Summary
Staff failed to follow the registered dietician's (RD) nutrition orders for a resident with spastic quadriplegia cerebral palsy who was receiving nutrition via both a gastrostomy and jejunostomy tube due to severe dysphagia and cognitive impairment. The RD's order specified that the resident should receive Osmolyte 1.5 continuously at 32ml/hour via the jejunostomy tube, with a one-hour stop time for residual checks. However, observations revealed that the tube feeding pump was turned off and disconnected from 10:00 AM to 2:00 PM daily, contrary to the RD's continuous feeding order. Staff interviews confirmed this practice, with an LPN stating the feeding was held for four hours each day, and the VP for Nutrition and DON both acknowledging that the only current order was for continuous feeding with a one-hour hold for residual checks. Record review showed that previous orders for intermittent feeding had been discontinued, and the current order was for continuous feeding to address the resident's history of vomiting. Despite this, staff continued to implement a prolonged feeding hold not supported by the current physician or RD orders. This deviation from prescribed nutrition orders placed the resident at risk for health complications and weight loss.
Failure to Implement Enhanced Barrier Precautions for Residents with Feeding Tubes
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents who shared a room and both had feeding tubes for nutrition. Both residents were admitted with cerebral palsy and were assessed as severely cognitively impaired, requiring tube feeding due to dysphagia. Their care plans included interventions for EBP, but these precautions were not followed during care activities. Specifically, a registered nurse provided oral care to one resident without wearing a gown, and a certified nursing assistant was unaware of the need for EBP when providing care to both residents. Observations and interviews confirmed that staff did not utilize the required personal protective equipment (PPE) or post appropriate signage indicating the need for EBP. The Director of Nursing acknowledged that EBP should have been implemented, including the use of PPE and signage, but these measures were not in place at the time of the survey. This lapse was identified through direct observation, staff interviews, and review of medical records and care plans.
Ineffective Pest Control Program Leads to Roach Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of roaches in five out of eight resident rooms. Observations confirmed sightings of live and dead roaches in various locations within the rooms, including dresser drawers, cabinets, sink counters, floors, and walls. Resident interviews corroborated these findings, with one resident reporting daily sightings of roaches and the need to shake out her clothes. Pest sighting logs documented numerous reports of ants, gnats, roaches, and spiders over several years, with recent reports indicating multiple sightings of ants and roaches. The facility's pest control program, as outlined in their policy, was not effectively implemented. Pest control technician reports highlighted sanitation issues, noting that areas such as nurses' desks and resident dresser drawers were not adequately cleaned, contributing to the persistence of the roach problem. Despite pest control treatments, the technician observed that the lack of sanitation allowed roaches to return. Interviews with staff and the administrator revealed awareness of the infestation issue, but the facility's operational reports did not comprehensively address pest control concerns in all affected rooms.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that call lights were accessible to two residents, R51 and R38, which could lead to delayed assistance and medical attention. R51, who has a history of aphasia, hemiplegia, and muscle weakness, was observed multiple times with the call light on the floor beside the bed, out of reach. Staff interviews confirmed that the call light should have been placed on the bed or pillow for accessibility, but this was not done, indicating a lapse in ensuring the resident's needs were met. R38, diagnosed with Parkinson's disease and muscle contractures, was found in bed with food on his mouth and clothes, unable to reach the call light due to his contracted condition. Although staff claimed R38 could use his voice to call for help, observations showed he was unable to press the call light. Interviews with staff revealed inconsistencies in their understanding of R38's ability to use the call light, with some staff members admitting the call light was not positioned correctly for the resident's use. The Director of Nursing and other staff members acknowledged the importance of having call lights accessible to residents, yet the facility lacked a specific policy on call light placement. This deficiency in ensuring call light accessibility for residents R51 and R38 highlights a failure in the facility's responsibility to accommodate the needs and preferences of its residents, potentially leading to delayed care and dissatisfaction with the level of care provided.
Failure to Honor Resident's Right to Choose Nap Time
Penalty
Summary
The facility failed to honor a resident's right to make personal choices, specifically regarding the desire to return to bed for a nap. The resident, identified as R8, has a medical history that includes a cerebrovascular accident with right-sided hemiparesis, hypertension, type 2 diabetes mellitus, depression, anxiety, dementia, insomnia, and muscle weakness. Despite having a Brief Interview for Mental Status (BIMS) score indicating little to no cognitive impairment and a care plan that emphasized the importance of making personal choices, R8's request to return to bed was not honored by the facility staff. On the day of the incident, R8 was observed sitting in a wheelchair and expressed a desire to return to bed for a nap before lunch. However, the Certified Nursing Assistant (CNA) II did not assist R8 back to bed, preferring to wait until after lunch to avoid multiple transfers. Interviews with the CNA, a Registered Nurse (RN), and the Director of Nursing (DON) confirmed that the resident's request should have been honored, as it is their right to decide when to lie down. This inaction by the staff led to a deficiency in honoring the resident's right to self-determination and choice, as outlined in the facility's document titled 'Your Rights and Protections as a Nursing Home Resident.'
Failure to Accurately Code Fall with Major Injury on MDS
Penalty
Summary
The facility failed to accurately code a fall with major injury on the Minimum Data Set (MDS) for a resident, identified as R14, who was reviewed for accidents. R14's medical history included fractures of the left tibia and fibula, which were noted as subsequent encounters for closed fractures with routine healing. On 8/13/2024, R14 sustained a fall while attempting to get out of bed without assistance, resulting in a proximal fracture to the left tibia. This incident required hospitalization and treatment without surgical intervention. However, the quarterly MDS assessments dated 8/19/2024, 10/23/2024, and 11/25/2024 failed to document this fall. The MDS Coordinator confirmed during an interview that the fall was not captured in the assessments and acknowledged the oversight.
Failure to Revise Care Plan for Restorative Services
Penalty
Summary
The facility failed to revise the care plan for a resident, identified as R8, who had a history of cerebrovascular accident (CVA) with right-sided weakness and contractures in the right upper and lower extremities. The care plan did not address the resident's refusals of restorative care, including the use of splints, nor did it document any alternative interventions or strategies to encourage participation. Observations over several days revealed that the resident was not wearing the prescribed splints, and interviews with staff confirmed that the refusals were not documented in the care plan prior to the survey. The facility's policy on Restorative Nursing Programs required that a resident's plan include specific details such as the problem, type of activities, frequency, duration, measurable goals, and target dates. However, the care plan for R8 lacked documentation of refusals and alternative interventions. Interviews with the RN, Restorative Aide, and MDS Coordinator revealed that the care plan had not been updated to reflect the resident's refusals and the necessary strategies to encourage compliance until after the survey. This oversight led to inconsistencies in the provision of restorative services for the resident.
Deficiencies in ADL Care and Hygiene
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) care for three residents, leading to deficiencies in personal hygiene and grooming. Resident 8, who has a history of cerebrovascular accident, diabetes, and vision impairment, was observed with long, dirty fingernails that were causing discomfort. Despite the resident's cognitive awareness and ability to communicate, the staff did not address the issue until it was brought to their attention by surveyors. The Director of Nursing (DON) acknowledged that nail care should be part of the routine grooming process, especially for diabetic residents, to prevent health risks. Resident 38, diagnosed with Parkinson's disease and moderate cognitive impairment, was also found with long, unkempt nails. Although the resident was dependent on staff for ADL care, the nails were not clipped despite being cleaned. The staff mentioned that the resident often refused nail care, but upon inquiry, the resident expressed discomfort and a willingness to have the nails clipped. The DON and other staff members recognized the need for better monitoring and care to prevent the nails from becoming a health hazard. Resident 16, with a history of hemiplegia and mild cognitive impairment, did not receive regular showers as per the facility's schedule. The resident's skin was observed to be dry and scaly, indicating a lack of proper hygiene care. The facility's records showed inconsistencies in the documentation of showers, and staff interviews revealed that missed or refused showers were not consistently reported or documented. The lack of adherence to the shower schedule and inadequate documentation contributed to the resident's unmet hygiene needs.
Failure to Provide Restorative Services for Resident
Penalty
Summary
The facility failed to provide consistent restorative services for a resident identified as needing such care. The resident, who has moderate cognitive impairment and requires substantial assistance with daily activities, had physician orders for a right knee contracture splint and a right wrist/hand contracture splint to increase range of motion and prevent contractures. Despite these orders and a discharge recommendation from physical therapy for a restorative splint and brace program, there was no documentation of the resident receiving these restorative services. Observations over several days confirmed that the resident was not wearing the prescribed splints, and interviews with the resident revealed that he was unaware of ever having worn a splint and expressed a desire for assistance. Interviews with facility staff, including a registered nurse and a restorative aide, indicated a lack of awareness or documentation regarding the resident's restorative care needs. The Director of Nursing acknowledged that the resident was supposed to receive restorative services but could not provide documentation due to system acquisition issues. The facility's failure to document and provide the necessary restorative services for the resident was not rectified before the survey exit, indicating a deficiency in the facility's adherence to its restorative nursing program policy.
Medication Storage and Expired Medication Deficiencies
Penalty
Summary
The facility failed to adhere to its medication storage policies, resulting in two significant deficiencies. Observations revealed that medication carts on the 100-Hall and 200-Hall were left unlocked and unattended during medication administration. Registered Nurse (RN) JJ was observed removing medications from the carts and entering residents' rooms without securing the carts. Interviews with RN JJ, the Director of Nursing (DON), and Unit Manager (UM) MM confirmed that the carts should have been locked when not in use to prevent unauthorized access, which could lead to adverse outcomes if residents accessed the medications. Additionally, the facility did not remove expired medications from the medication carts on the 100-Hall and 500-Hall. Observations identified several expired medications, including iron tablets, aspirin, and ferrous sulfate, which had not been removed from the carts. Interviews with RN JJ, Licensed Practical Nurse (LPN) LL, and UM HH confirmed the presence of expired medications and acknowledged that administering these could result in medication errors and adverse reactions. The DON and UM MM stated that expired medications should be promptly removed by licensed nurses to prevent potential harm to residents.
Deficiency in Restorative Nursing Documentation
Penalty
Summary
The facility failed to maintain and document accurate medical records for a resident receiving restorative nursing services. The resident, who had a history of cerebrovascular accident (CVA) with right-sided weakness and contractures, was supposed to receive restorative services, including passive range of motion (ROM) exercises and splint application, as per physician orders and physical therapy recommendations. However, a review of the resident's medical records revealed no documentation of these services being provided, despite the facility's policy requiring such documentation. Interviews with the Director of Nursing and the Restorative Aide confirmed the absence of documentation for the restorative services. The Director of Nursing acknowledged the lack of records and attributed it to system acquisition issues following a transition from previous ownership. The Administrator also confirmed the documentation gaps and noted challenges in accessing the electronic medical record (EMR) system due to the transition, which hindered the retrieval of historical medical records.
Inadequate Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to maintain proper infection control protocols during wound care for a resident with a stage 4 pressure ulcer. The facility's policy on hand hygiene, dated February 1, 2024, mandates that all staff perform hand hygiene procedures to prevent the spread of infection. This includes sanitizing hands before donning gloves and immediately after removing them. However, during an observation on January 8, 2025, the Wound Care Nurse (WCN) was seen changing gloves without sanitizing her hands in between, which is a violation of the facility's hand hygiene policy. The resident involved, identified as having intact cognition and a stage 4 pressure ulcer, was receiving wound care as per physician's orders. The WCN admitted to not sanitizing her hands between glove changes, acknowledging the risk of infection to the resident. Interviews with the Unit Manager and Director of Nursing confirmed that the expected protocol was not followed, emphasizing the importance of hand hygiene in preventing infections and ensuring proper wound care.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
