Crossroads Of Flowery Branch Of Journey Llc, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Flowery Branch, Georgia.
- Location
- 4595 Cantrell Road, Flowery Branch, Georgia 30542
- CMS Provider Number
- 115327
- Inspections on file
- 21
- Latest survey
- January 16, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Crossroads Of Flowery Branch Of Journey Llc, The during CMS and state inspections, most recent first.
Two residents with significant medical conditions, including dementia and heart failure, made allegations of staff-to-resident abuse that were reported to facility staff but not reported to administration or the State Survey Agency within the required timeframe. Facility staff, including the DON and SSD, failed to document, report, or investigate these allegations as required by policy, resulting in a lack of appropriate response to the reported incidents.
The facility did not properly identify or investigate allegations of staff-to-resident abuse for two residents. In one case, a resident with dementia and on hospice care reported being hurt by staff, but no investigation was conducted. In another case, a cognitively intact resident was found with bruising, but the investigation lacked interviews with the resident and other residents, and there was no analysis of the cause or staff training on abuse reporting.
Two residents experienced significant weight loss that was not accurately coded in their MDS assessments. One resident with dysphagia lost over 8% of body weight, and another with Parkinson's disease lost over 13% in a month, but these losses were not documented in the MDS. Staff interviews confirmed the omissions, and the DON acknowledged the expectation for accurate MDS coding.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the care plan was not prepared, reviewed, and revised by a team of health professionals as required.
A deficiency was cited when a resident was not provided with sufficient food and fluids to maintain their health, as required. The report does not include further details about the circumstances or the resident's condition.
The facility failed to ensure that two CNAs completed the required in-service training hours, with CNA AA completing only 5.5 out of 6 hours and CNA FF completing 1.15 out of 12 hours. This deficiency was identified during a staff development review. Interviews revealed a lack of awareness and oversight, with management collectively responsible for overseeing in-services but no designated person for the task. The ADON and CNA AA were unaware of the non-compliance, while the DON expected all CNAs to complete their in-service hours to ensure resident safety.
The facility failed to document and communicate resolutions to resident concerns voiced during Resident Council meetings. Despite the policy requiring follow-up, the Activity Director and DON acknowledged that resolutions were not documented, leaving residents unaware of outcomes or grievance procedures.
The facility failed to maintain a safe and homelike environment, with six resident rooms having furniture in disrepair and leaking PTACs. Dressers in several rooms were missing drawers or knobs, and PTACs in other rooms leaked water onto the floors. The Maintenance Director confirmed these issues, citing extreme heat and condensation as causes for the PTAC leaks, and noted challenges in addressing these problems due to working alone.
CNAs in the facility failed to use hand sanitizer between distributing lunch trays to residents, despite being reminded by an RN. The CNAs admitted to forgetting the practice and had not received handwashing training since starting at the facility. The DON confirmed the expectation for proper hand hygiene to prevent infection control issues.
A resident with multiple chronic conditions experienced a significant change in condition, including altered mental status and respiratory distress, leading to transfer to the ED. Despite assessments and actions taken by nursing staff and a nurse practitioner, there was no timely documentation of the change of condition or the events leading to the transfer in the medical record, nurses' notes, 24-hour report, or SBAR report. The deficiency was only identified after surveyor inquiry, prompting late entries.
Failure to Timely Report and Investigate Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of staff-to-resident abuse to facility administration and/or to the State Survey Agency (SSA) within the required two-hour timeframe for two residents. For the first resident, who had diagnoses including dementia, anxiety, malnutrition, and muscle weakness and was on hospice care, allegations of being hurt by staff resulting in bruising and wounds were reported to the Social Service Worker (SSW) on two occasions. The SSW reported these allegations to the Administrator and Social Service Director (SSD), but there was no evidence that the facility reported or investigated the incidents as required. The Director of Nursing (DON) and SSD acknowledged awareness of the allegations but did not report or document them, with the DON attributing one bruise to a prior fall and the Administrator expressing personal doubts about the validity of the reports, which led to no investigation or reporting. For the second resident, who had heart failure, kidney failure, depression, hypertension, muscle weakness, and was also on hospice care, complaints of rough treatment by staff were made to both the resident's family and facility staff. A Certified Nurse Aide (CNA) reported to the SSD that the resident alleged a staff member had held her hand too hard and caused pain. The SSD documented the allegation in a daily planner but did not report or investigate the incident, and could not recall the reporting CNA. The Administrator later confirmed a lack of awareness and concern that these issues were not reported or investigated as required. These failures were in direct violation of the facility's policy, which mandates immediate reporting of all alleged violations.
Failure to Investigate Allegations of Staff-to-Resident Abuse
Penalty
Summary
The facility failed to identify and/or investigate allegations of staff-to-resident abuse for two residents. For the first resident, who had diagnoses including dementia, anxiety, malnutrition, and muscle weakness and was on hospice care, there were two separate reports made by a hospice social worker that the resident claimed to have been hurt by staff, resulting in bruising and wounds. These reports were communicated to both the facility Administrator and Social Service Director, but there was no evidence that any investigation was initiated or documented by the facility. The Director of Nursing confirmed that no investigation was conducted, and the Administrator could not locate any report of the allegations, acknowledging that they should have been investigated. For the second resident, who was cognitively intact and had multiple medical conditions, a family friend reported bruising, which was subsequently reported to the Administrator. While an incident report was created and some staff interviews were conducted, there was no documentation that the resident was interviewed, that other residents were questioned, or that the cause of the bruising was analyzed. Additionally, there was no evidence of staff training on reporting or investigating injuries of unknown origin, nor documentation of measures to protect the resident or prevent recurrence. The Administrator admitted to being unaware that the investigation was incomplete and agreed that all such allegations should be thoroughly investigated.
Failure to Accurately Code Significant Weight Loss in MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were accurately coded to reflect significant weight loss for two residents. For one resident with dysphagia, weight records showed a loss of 8.73% over a short period, but the quarterly MDS assessment did not document this significant weight loss. The resident's care plan noted a risk for weight loss but did not address the actual significant loss that had occurred. During observation, the resident expressed concerns about being skinny, further indicating awareness of her weight change. For another resident with Parkinson's disease and other brain disorders, weight records indicated a 13.54% loss in one month, but the quarterly MDS assessment failed to code this significant weight loss. Progress notes showed interventions such as appetite stimulation and dietician involvement, and the care plan was revised to note significant weight loss at a later date. Staff interviews confirmed that the MDS assessments for both residents did not reflect the significant weight loss, and the DON acknowledged that the MDS should have included this information.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Failure to Provide Adequate Nutrition and Hydration
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide adequate food and fluids necessary to maintain a resident's health. The report notes that the required provision of nutrition and hydration was not met, which is essential for the resident's well-being. Specific details about the actions or inactions leading to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Deficiency in CNA In-Service Training Hours
Penalty
Summary
The facility failed to ensure that two of its Certified Nursing Assistants (CNAs) completed the minimum required in-service training hours during the review period from February 1, 2023, to January 31, 2024. Specifically, CNA AA, who worked part-time, completed only 5.5 hours out of the required 6 hours, and CNA FF, who worked full-time, completed only 1.15 hours out of the required 12 hours. This deficiency was identified during a staff development review conducted on July 5, 2024, as documented in the Alliant Certified Nursing Assistant (CNA) Annual Report. The facility's policy mandates that each nurse aide must receive at least 12 hours of in-service training annually, based on their employment date. Interviews with facility staff revealed a lack of awareness and oversight regarding the completion of in-service training hours. The Assistant Director of Nursing (ADON) stated that management was collectively responsible for overseeing in-services and education, but there was no designated person for this task. The ADON was unaware of the non-compliance of CNAs AA and FF with their in-service hours. Similarly, CNA AA was not aware of her shortfall in meeting the in-service education requirement, although she believed she had completed the necessary training. The Director of Nursing expressed an expectation that all CNAs should have their in-service hours completed to prevent potential negative outcomes affecting resident safety.
Failure to Document and Communicate Resolutions to Resident Concerns
Penalty
Summary
The facility failed to ensure proper follow-up and communication regarding resident concerns and recommendations voiced during Resident Council meetings. The review of the facility's policy on Resident Council Meetings indicated that the Activity Director was responsible for facilitating meetings and responding to written requests from the group. However, the facility did not document responses to concerns or recommendations, nor did they provide evidence of thorough investigation or resolution of these issues. This lack of documentation and follow-up was evident in the review of nine Resident Council meeting minutes, which were incomplete and lacked evidence of resolution or satisfaction from the residents. During a Resident Council Meeting, several residents expressed that they had voiced concerns and recommendations but had not received any follow-up or resolutions. Additionally, these residents were unaware of how to file a grievance or who the grievance official was. Interviews with the Activity Director and the Director of Nursing revealed that while concerns were verbally communicated to residents, there was no documentation of resolutions. The Director of Nursing acknowledged the need for documentation and expressed that staff were expected to document resolutions to residents' concerns.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by the disrepair of furniture and packaged terminal air conditioners (PTACs) in six out of 56 resident rooms. Specifically, rooms A6-2, B10-1, and C18-2 had dressers with missing drawers and/or knobs, while rooms C13, C15, C18, and C19 had PTACs that leaked water onto the floors. These deficiencies were identified through observations, resident and staff interviews, and a review of the facility's maintenance policy. The policy required routine inspections and immediate correction of any issues, which were not adhered to in this case. During an interview, the Maintenance Director confirmed the observations and acknowledged that the PTACs had been leaking intermittently over the past month due to extreme heat causing increased condensation. Despite the units still functioning, they were not effectively directing the fluid outside, leading to water accumulation on the floors. The Maintenance Director, who worked alone, stated that he cleaned the affected floors every two to three days but had no immediate plans to replace the PTACs. He also mentioned difficulties in conducting routine rounds due to his workload, which contributed to the ongoing issues with the facility's environment.
Failure to Maintain Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to maintain proper hand hygiene practices, which are crucial for preventing infections and cross-contamination. During an observation on Hall A, Certified Nursing Assistants (CNAs) were seen distributing lunch trays to residents without using hand sanitizer between each delivery. Despite being reminded by a Registered Nurse (RN) to use hand sanitizer, the CNAs continued to neglect this practice. This oversight was observed in multiple rooms, indicating a pattern of non-compliance with the facility's hand hygiene policy. Interviews with the CNAs revealed that they were aware of the requirement to use hand sanitizer but admitted to forgetting to do so. Both CNAs also disclosed that they had not received any handwashing hygiene training since starting their employment at the facility, although they had learned about it during their initial CNA training. The Director of Nursing confirmed that the expectation was for all CNAs to adhere to proper hand hygiene protocols to prevent infection control issues and ensure resident safety.
Failure to Document Change of Condition and Transfer
Penalty
Summary
The facility failed to ensure accurate and timely documentation of a resident's change of condition, as required by its own policy and professional standards. A resident with multiple complex diagnoses, including hypertensive heart and chronic kidney disease, end stage renal disease, dementia, and dependence on dialysis, experienced a significant change in condition characterized by altered mental status, fever, and respiratory distress. The resident was ultimately sent to the emergency department, where diagnoses included hypernatremia, dehydration, acute respiratory failure, sepsis, and pneumonia. Despite these events, there was no documentation in the resident's medical record, nurses' notes, 24-hour report, or SBAR report regarding the change of condition or the events leading to the transfer. Staff interviews confirmed that the nurse and nurse practitioner assessed the resident and arranged for transfer to the hospital, but failed to document the assessment, observations, or rationale for the transfer at the time of the event. The nurse practitioner only wrote an order to send the resident out, without specifying the reason, and the LPN believed she had charted the information but had not. The CNA reported changes in the resident's behavior and communicated this to the nurse, who then took action, but again, no documentation was made at the time. The lack of documentation was only discovered after surveyor inquiry, at which point late entries were made.
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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