Crossview Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pineview, Georgia.
- Location
- 402 E. Bay St, Pineview, Georgia 31071
- CMS Provider Number
- 115541
- Inspections on file
- 18
- Latest survey
- December 4, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Crossview Care Center during CMS and state inspections, most recent first.
The facility failed to provide showers or baths according to the preferences and schedules of three residents, leading to a deficiency in promoting resident self-determination. One resident, with a history of aphasia and hemiplegia, received fewer showers than scheduled despite grievances. Another resident with COPD and diabetes also received showers less frequently than scheduled. A third resident, with cerebral infarction and schizophrenia, reported that showers were not given due to a lack of towels. Staff interviews revealed issues with linen availability, affecting the ability to provide showers as scheduled.
A resident with multiple diagnoses, including Alzheimer's and dementia, was found with a significant bruise around the left eye that was not reported to the State Agency within the required time frame. Staff interviews revealed uncertainty about the cause of the bruise, and the facility administrator confirmed that no report had been made until prompted by a surveyor's inquiry, violating the facility's policy and regulatory requirements.
A resident with multiple diagnoses, including dementia and intellectual disabilities, was found with a bruise on the left eye on two occasions, but the facility failed to investigate or report the injury as required by their abuse prevention policy. Interviews with staff, including an LPN and the administrator, revealed a lack of documentation and clarity regarding the incident, leading to a deficiency in the facility's handling of the situation.
The facility failed to accurately report direct care staffing data to CMS for Q1 2024, resulting in a one-star staffing rating. Discrepancies were found between the actual nursing hours worked on weekends and the hours reported. Current leadership was unable to explain the discrepancies, as they were not in their positions during the period in question.
The facility failed to maintain a clean and sanitary environment in the laundry department, leading to potential cross-contamination of dirty and clean laundry. Observations revealed spider webs, dust buildup, and grime on various surfaces, as well as a leaking handwashing sink. Staff interviews confirmed that daily cleaning was not adequately performed.
The facility failed to ensure that four residents did not have unsecured unauthorized medications stored at their bedside. The residents had various medications and antiseptic products in their rooms without being assessed for self-administration. Staff were unaware of these items, and the Director of Nursing confirmed that none of the residents were care planned or assessed to self-administer medications.
The facility failed to maintain a safe, clean, and homelike environment in the 100 Hall, with issues such as a loose handrail, jagged door frames, rusty heaters, and damaged flooring. Specific rooms and bathrooms had peeling paint, stained tiles, and jagged edges, which were confirmed by the Administrator, Maintenance Director, and Housekeeping Supervisor.
The facility failed to follow the care plan for a resident with COPD, resulting in the resident receiving an incorrect oxygen level. Observations and staff interviews confirmed that the oxygen was set at 4.5 L/M, contrary to the physician's order.
A resident with COPD was observed receiving oxygen at 4.5 L/M instead of the physician-ordered 2 L/M. Staff were unaware of the correct setting, and the resident confirmed she did not alter the oxygen levels. The DON and MDS Coordinator acknowledged the failure to follow the physician's orders, putting the resident at risk.
Failure to Provide Scheduled Showers/Baths
Penalty
Summary
The facility failed to ensure that three residents received showers or baths according to their preferences and scheduled days, leading to a deficiency in promoting resident self-determination and choice. Resident 1, who had a history of aphasia, dysphagia, and hemiplegia, was scheduled for showers on Mondays, Wednesdays, and Fridays but received fewer showers than scheduled. Despite grievances filed by the resident and their family, the facility did not consistently provide showers as per the resident's preference. Resident 2, diagnosed with COPD, diabetes, and hemiplegia, was scheduled for showers on Tuesdays, Thursdays, and Saturdays. However, the resident received showers less frequently than scheduled, and a grievance was filed when the resident did not receive a shower for a week. Similarly, Resident 3, with a history of cerebral infarction and schizophrenia, was scheduled for showers on Mondays, Wednesdays, and Fridays but did not receive them consistently. The resident reported that staff documented refusals when, in fact, showers could not be given due to a lack of towels. Interviews with staff revealed that the facility faced issues with linen availability, which affected the ability to provide showers as scheduled. Certified Nursing Assistants reported that baths could not be given at times due to a lack of clean linens, and the Director of Nursing confirmed that there had been issues with linen availability. Despite these challenges, the facility did not adequately address the residents' preferences and needs for personal hygiene, leading to the deficiency.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident to the State Agency within the required time frame. According to the facility's policy, any alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, must be reported immediately, but not later than 2 hours if they involve abuse or result in serious bodily injury, or within 24 hours if they do not. The resident in question, who had diagnoses including intellectual disabilities, Alzheimer's disease, and dementia, was observed with a significant bruise around the left eye that had not been evaluated or reported in a timely manner. Interviews with staff revealed uncertainty about the cause of the bruise, with a CNA noting the injury was present after returning from days off, and an LPN suggesting a possible fall but finding no documentation to confirm this. The facility administrator admitted to completing a report to the state only after being prompted by the surveyor's inquiry, confirming that no prior report of the injury had been made. This delay in reporting violated the facility's policy and regulatory requirements for timely notification of injuries of unknown origin.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for a resident, identified as R6, who was admitted with multiple diagnoses including intellectual disabilities, Alzheimer's disease, dementia with agitation, generalized anxiety disorder, major depressive disorder, dysphagia, and a need for assistance with personal care. The deficiency was identified through a review of the facility's policy on abuse prevention, which mandates immediate reporting and investigation of any suspected abuse, mistreatment, or neglect. Despite this policy, the facility did not evaluate or report a bruise found on R6's left eye on two separate occasions. Interviews with staff revealed a lack of clarity and documentation regarding the incident. An LPN suggested that R6 might have fallen but could not find any documentation to support this claim. The facility's administrator confirmed that no incident report had been completed for the bruising and acknowledged that the staff did not follow the expected procedures for reporting and documenting such incidents. This lack of action and documentation led to the deficiency noted in the report.
Inaccurate Reporting of Direct Care Staffing Data
Penalty
Summary
The facility failed to accurately report direct care staffing data to CMS for the first quarter of Fiscal Year 2024. A review of the PBJ Report for Q1 2024 revealed that the facility triggered a one-star staffing rating due to excessively low weekend staffing, failure to submit PBJ data by the deadline, more than four days in the quarter without RN staffing hours, and failure to respond to or pass a CMS audit designed to discover discrepancies in PBJ data. Discrepancies were found between the total number of hours nursing staff worked on weekends and the total number of nursing hours reported to CMS. Interviews with the Director of Nursing (DON), the Administrator, and the Regional President revealed that the current leadership was unable to explain the discrepancies, as they were not in their positions during the period in question. The DON reported working weekends and weekdays to ensure coverage, and the Regional President acknowledged the one-star staffing rating and stated that the facility was currently in compliance with RN coverage and staffing. The former leadership, including the previous Administrator and DON, were no longer working at the facility, making it difficult to determine the baseline and the cause of the staffing shortages and inaccuracies in the PBJ reports submitted.
Infection Control Deficiency in Laundry Department
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in the laundry department, leading to potential cross-contamination of dirty and clean laundry. Observations during a tour revealed spider webs and a buildup of dust on walls, ceiling tiles, pipes, and behind washing machines and dryers. Additionally, there was a heavy accumulation of dust, dirt, and grime on pipes, electrical cords, and the floor behind the machines. Heavily soiled and dusty cloths were used as fillers around the air conditioning unit in the clean sorting and folding area. A pink bath pan under the handwashing sink was filled with dark-colored liquid, indicating a leak that had been present long enough for the liquid to overflow onto the floor, with unidentifiable black spots on the rim of the pan. Interviews with staff revealed that the facility was using agency staff for housekeeping and laundry. The Housekeeping Manager confirmed that staff were supposed to clean the laundry area daily, but acknowledged the presence of dust and other cleanliness issues. The Maintenance Director and Corporate Maintenance were unaware of the cleaning and maintenance issues in the laundry department until they reviewed pictures and confirmed the unsanitary conditions. The Administrator stated that her expectations were for the laundry department to be clean and sanitary, and mentioned that a new AC/heat unit was needed in the folding/sorting room, which required a capital expenditure request to corporate due to the cost exceeding $500.
Unsecured Unauthorized Medications Found in Residents' Rooms
Penalty
Summary
The facility failed to ensure that four residents did not have unsecured unauthorized medications stored at their bedside. Resident 3, who had diagnoses including Type 2 diabetes, schizophrenia, Alzheimer’s, and hypertension, was observed with medicated creams on her bedside table. She reported using the cream daily, although she had not been assessed to self-administer medications. Similarly, Resident 10, with diagnoses including gastro-esophageal reflux disease and mild cognitive impairment, had peroxide and mupirocin ointment in her bathroom. She stated that her wound nurse gave her the ointment to self-apply, but she had not been assessed for self-administration either. Resident 22, with chronic obstructive pulmonary disease and mild cognitive impairment, had oral tooth gel on his nightstand, which he reported using for mouth pain. He also had not been assessed for self-administration. Resident 27, with heart disease, Type 2 diabetes, and hypertension, had mouthwash and rubbing alcohol in her bathroom and artificial tears on her bedside table. She reported using these items without supervision, but she had not been assessed for self-administration either. During rounds with the Director of Nursing (DON) and an LPN, all medications and antiseptic products were confirmed in the residents' rooms. Both staff members were unaware of the medications and products. The DON reported that none of the residents were care planned or assessed to self-administer medications or antiseptic products. The DON removed the medications from the residents' rooms and noted that some items, like the artificial tears, should be kept at the nurse station. The DON also mentioned that the facility has a monitoring system called Angels Guardian Rounds to inspect rooms for unauthorized items, but she had not been in the residents' rooms lately. An LPN confirmed that the eyedrops were in Resident 27's room and denied leaving them there. She also stated that zinc ointment or any incontinent cream items should be placed in a secure place and not left at the bedside. The LPN reported being unaware of Resident 27 using the vaginal cream independently and mentioned that nurses would typically apply such creams for infection control. She also stated that nurses and certified nursing assistants were educated to place these items in a secure place after use.
Environmental Deficiencies in 100 Hall
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for residents in the 100 Hall. Observations revealed a loose handrail along the interior corridor, jagged and rough edges on the exit door frame, an old rusty inoperable heater attached to the wall, and chipped and scratched flooring near the dining area. These issues were confirmed by the Administrator and the Maintenance Director during walking rounds. Additionally, the Maintenance Director acknowledged that the handrail and flooring needed repairs, but approval from the corporate office was required for the flooring fix. Further observations identified environmental concerns in specific rooms and bathrooms. Room 13 had peeling paint exposing dirty tiles and scraped closet and bathroom doors. Room 10's bathroom floor tiles were stained with a dark brown sticky substance, and the bathroom door was damaged, preventing closure. Room 4 had scraped closet doors with protruding sharp jagged edges. The exit door frame had missing parts causing jagged sharp edges, and a wall-mounted heater near the exit door was covered with rust. Room 8's bathroom had two uncovered basins on the floor with dirt and debris, and dark wet coffee-colored stains coating the tiles near the commode. These issues were confirmed by the Maintenance Director, Administrator, and Housekeeping Supervisor, who acknowledged the environmental deficiencies and the need for repairs.
Failure to Implement Care Plan for Oxygen Administration
Penalty
Summary
The facility failed to implement the care plan for a resident (R17) related to oxygen administration. The resident was admitted with a diagnosis of chronic obstructive pulmonary disease (COPD) and shortness of breath. The care plan indicated that the resident required supplemental oxygen, with specific oxygen settings as ordered by the physician. However, during observations on two separate occasions, the surveyor noted that the resident's oxygen level was set at 4.5 L/M, which was not in accordance with the physician's order. This discrepancy was confirmed through interviews with the Director of Nursing (DON) and the MDS Coordinator, who both stated that the expectation was for nurses to monitor and ensure the oxygen is set at the correct level per the physician's order and to follow the resident's care plan. The facility's policy titled RAI/Care Planning Management emphasized the importance of conducting a comprehensive and accurate assessment of each resident's functional capacity and ensuring that care plans are accessible for clinical staff to facilitate care plan interventions. Despite this policy, the facility did not adhere to the care plan for R17, leading to the deficiency. The DON and MDS Coordinator acknowledged that the care plan was not followed, which resulted in the resident receiving an incorrect oxygen level.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to ensure that oxygen was administered as ordered by the physician for a resident with chronic obstructive pulmonary disease (COPD) and shortness of breath. The physician's order specified that the resident should receive oxygen at 2 liters per minute (L/M) continuously via nasal cannula. However, during an initial screening, the surveyor observed that the oxygen was set at 4.5 L/M. This discrepancy was confirmed by two Licensed Practical Nurses (LPNs) who were unaware of the correct oxygen setting as per the physician's order. The resident confirmed that she did not alter the oxygen settings herself, indicating that the staff failed to monitor and adjust the oxygen levels as required. Further interviews with the Director of Nursing (DON) and the MDS Coordinator revealed that the facility's policy and the resident's care plan both required the oxygen to be administered as ordered by the physician. The DON acknowledged that failing to adhere to the prescribed oxygen levels could put the resident at risk of adverse reactions, especially given her COPD diagnosis. The MDS Coordinator also emphasized that nurses are expected to follow the physician's orders and the resident's care plan, which was not done in this case.
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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