Dawson Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Dawson, Georgia.
- Location
- 1159 Georgia Ave. S.e., Dawson, Georgia 39842
- CMS Provider Number
- 115483
- Inspections on file
- 16
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Dawson Health And Rehabilitation during CMS and state inspections, most recent first.
A resident with severe cognitive impairment was physically abused by a CNA, witnessed by three other CNAs who failed to intervene or report the incident immediately. The abuse included hitting, arm twisting, and suffocation attempts, causing physical harm. The facility's policy on immediate reporting of abuse was not followed, leading to a deficiency in resident protection.
A resident was found unresponsive with an arm trapped between a bedrail and mattress due to incorrect mattress dimensions and lack of informed consent for bedrail use. The facility failed to ensure bedframes were equipped with the correct mattress size, affecting 47 residents and increasing entrapment risk. Staff interviews revealed inadequate policies and education on bedrail use.
The facility failed to ensure correct mattress sizing for 47 beds, leading to a resident's entrapment and subsequent unresponsiveness. Additionally, a resident was physically abused by staff, with witnesses failing to intervene. These incidents highlight significant deficiencies in resource management and resident protection.
A resident with intact cognition was found with medication at their bedside without a self-administration assessment, contrary to facility policy. Staff interviews confirmed that medications should not be left at the bedside without proper authorization, highlighting a lapse in policy adherence.
A facility failed to accurately document a resident's code status, leading to a potential risk of unwanted CPR. The resident's POLST indicated a DNR status, but the EMR and physician's orders showed a full code. Interviews with staff confirmed the inconsistency, which could result in actions contrary to the resident's and family's wishes.
A resident experiencing acute pain due to trauma missed three doses of prescribed tramadol because the medication was not delivered, and the physician was not notified. Additionally, the resident could not complete a scheduled x-ray due to pain, and again, the physician was not informed. Interviews with facility staff revealed an expectation for the nursing staff to notify the physician in such situations, which was not met, preventing necessary adjustments to the resident's care plan.
A facility failed to accurately complete a comprehensive social assessment for a resident with undifferentiated schizophrenia and mild intellectual disabilities. The resident's diagnoses were not reflected in the assessments signed by the Social Service Director, who was unaware of these conditions. The RAI Director confirmed the expectation for accurate assessments, although no specific policy was in place.
A facility failed to conduct an accurate Level I PASRR for a resident with Undifferentiated Schizophrenia and mild intellectual disabilities. The resident's EMR showed these diagnoses, but the Comprehensive Social Assessment did not, and the SSD marked no history of mental illness. The hospital's Level I PASRR inaccurately marked 'No' for serious mental illness or intellectual disability, leading to the absence of a Level II screening. The SSD was unaware of the resident's diagnosis and followed a 'Best Practice for PASRR' document due to the lack of a specific policy.
A facility failed to develop a baseline care plan within 48 hours of a resident's admission, as required by policy. The Resident Assessment Instrument Director, responsible for this task, was on leave, and the duty was to be covered remotely by someone from the corporation, but it was not completed. The resident's electronic medical record showed no evidence of a baseline care plan.
A resident's care plan was not updated to address pain management despite complaints of lower back pain and administration of PRN Tylenol. The facility's policy requires care plans to address identified pain, but the resident's plan lacked any problems, goals, or interventions related to pain. This oversight was confirmed by facility staff, including the RN, RAI Director, and Medical Director, highlighting a risk for ineffective pain management.
A resident with a history of falls and mobility issues was found crawling on the floor without necessary safety measures in place, such as a low bed and fall mats, as outlined in their care plan. The resident sustained injuries due to inadequate supervision and failure to implement prescribed interventions, despite facility policies requiring such measures.
A resident experienced untreated pain due to the facility's failure to procure and administer tramadol as ordered by the physician. The resident, who had acute pain from a fall, missed three doses of the medication because the pharmacy was waiting for a signed prescription. The nursing staff did not follow procedures to use the emergency medication kit or notify the physician, leading to the resident's discomfort and an incomplete x-ray examination.
A facility failed to provide a written bed hold agreement for a resident transferred to a behavioral facility for medication stabilization. The resident, with moderate cognitive impairment and multiple health conditions, did not receive a signed agreement explaining room rates after the Medicaid bed hold expired, contrary to the facility's policy.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by a Certified Nursing Assistant (CNA1), which was witnessed by three other CNAs (CNA2, CNA3, and CNA4) who did not intervene or report the incident immediately. The abuse involved CNA1 hitting the resident in the face, twisting her arm, and placing a pillow over her face, causing physical harm. The incident was not reported to the Administrator or Director of Nursing (DON) until 30 minutes after it occurred, allowing the abuse to continue and putting other residents at risk. The resident involved, identified as R23, had a severely impaired cognitive status due to Alzheimer's dementia, as indicated by a Brief Interview for Mental Status (BIMS) score of 99. Her care plan noted cognitive impairment, memory problems, and behaviors such as physical aggression and agitation. Despite these challenges, the facility's staff failed to protect her from abuse and did not follow the care plan interventions, which included maintaining a calm manner and using a gentle tone of voice. The facility's investigation revealed that the CNAs who witnessed the abuse did not take immediate action to stop it or report it promptly. The DON confirmed that the CNAs were unable to explain their inaction and had not been adequately trained to intervene in such situations. The facility's policy required immediate reporting of abuse, but this was not adhered to, resulting in a deficiency in protecting residents from abuse and neglect.
Improper Bedrail and Mattress Use Leads to Resident Entrapment
Penalty
Summary
The facility failed to ensure that residents' bedframes were equipped with the correct mattress dimensions as per the manufacturer's manual, which increased the risk of entrapment. This deficiency was identified when a resident, referred to as R155, was found unresponsive with his upper left extremity trapped between the bedrail and the mattress. The facility's records revealed that 47 out of 55 residents had bed frames with incorrect mattress dimensions, posing a significant risk of entrapment. The report highlights that R155 was admitted to the facility and had bedrails added to his bed without obtaining informed consent. The assessment for the use of bedrails did not include necessary information such as medical necessity or alternative options. Observations showed that the bedrails had significant movement due to the incorrect mattress size, which was not in compliance with the manufacturer's recommendations. The Maintenance Director confirmed that the mattress used was not the recommended size, and the bedrails were installed with excessive movement, which contributed to the entrapment risk. Interviews with facility staff, including the Maintenance Director and the Regional Corporate Nurse, revealed a lack of policy or procedure related to bedrail use and inadequate education on the risks and benefits of bedrails. The Medical Director stated that consent for bedrail use was not typically obtained before implementation. The facility's inspection records showed that bed frames were not inspected as frequently as recommended by the manufacturer's manual, further contributing to the deficiency.
Deficiencies in Mattress Sizing and Resident Protection
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, resulting in two significant deficiencies. Firstly, the facility ordered mattresses that did not meet the manufacturer's recommended dimensions for the bed frames, affecting 47 out of 55 beds with bedrails. This oversight placed residents at risk of entrapment. A critical incident occurred when a resident was found unresponsive with their upper left extremity trapped between the mattress and bedrail, preventing a fall to the floor. Unfortunately, the resident could not be revived, highlighting the severe consequences of the facility's failure to ensure the correct mattress size. Secondly, the facility failed to protect a resident from physical abuse by a staff member, which was witnessed by three additional staff members who did not intervene. This incident underscores a failure in the facility's responsibility to prevent and report patient abuse, as outlined in the Administrator's job description. The survey team identified these systemic failures, resulting in Immediate Jeopardy related to the administration of the facility, specifically concerning the deficiencies in patient safety and protection from abuse.
Failure to Assess for Self-Administration of Medication
Penalty
Summary
The facility failed to assess a resident for self-administration of medication, which led to a potential safety issue. The resident, who had intact cognition as indicated by a perfect score on the Brief Interview for Mental Status, was observed with two capsules in a medicine cup on his bedside table. The resident was unaware of the medication's identity and mentioned that a Certified Medication Aide (CMA) had given them to him before he fell asleep. The facility's policy prohibits leaving medications at the bedside unless a self-administration assessment has been conducted and approved by the interdisciplinary team (IDT), which was not done in this case. Interviews with facility staff, including a Licensed Practical Nurse (LPN), the Administrator, a Registered Nurse (RN), and the Director of Nursing (DON), confirmed that the facility does not allow residents to self-administer medications without a proper assessment and doctor's order. The staff reiterated that medications should not be left at the bedside, and the facility's policy requires any unauthorized medications found at the bedside to be reported and returned. The incident highlighted a lapse in following the facility's medication administration policy, as the resident was left with medication without the necessary assessment and authorization.
Discrepancy in Code Status Documentation
Penalty
Summary
The facility failed to ensure the accurate documentation of a resident's code status in the medical record, which could lead to the resident receiving unwanted cardiopulmonary resuscitation (CPR). The discrepancy was found in the records of a resident with severe cognitive impairment, diagnosed with Alzheimer's disease and dementia. The physician's order and the electronic medical record (EMR) indicated a full code status, while the Physician Orders for Life-Sustaining Treatment (POLST) signed by the resident's daughter and physician indicated a Do Not Attempt Resuscitation (DNR) status. Interviews with the Director of Nursing (DON), Social Service Director (SSD), and Assistant Director of Nursing (ADON) confirmed the inconsistency in the resident's code status documentation. The SSD verified that the POLST, which was signed upon the resident's admission, indicated a DNR status, aligning with the family's wishes. However, the EMR and physician's orders incorrectly documented a full code status. This discrepancy was further highlighted when a Licensed Practical Nurse (LPN) stated she would initiate CPR based on the EMR's full code status, contrary to the POLST directive.
Failure to Notify Physician of Missed Medication and Incomplete X-ray
Penalty
Summary
The facility failed to notify the physician regarding a resident's missed medication doses and inability to complete a medical test due to pain. The resident, who was experiencing acute pain due to trauma, was prescribed tramadol, an opioid pain medication, to be taken twice daily. However, the resident missed three doses of tramadol because the medication was not delivered by the pharmacy, and the physician was not informed of this issue. Additionally, the resident was unable to complete a scheduled thoracic spine x-ray due to excessive pain, and again, the physician was not notified. Interviews with facility staff, including a Licensed Practical Nurse (LPN), a Registered Nurse (RN), the Director of Nursing (DON), and the Medical Director, revealed that there was an expectation for the nursing staff to notify the physician when the medication was not available and when the x-ray could not be completed. The failure to communicate these issues to the physician prevented the medical provider from making necessary adjustments to the resident's plan of care, which could have addressed the resident's pain and facilitated the completion of the x-ray.
Inaccurate Social Assessment for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure an accurate comprehensive social assessment for a resident diagnosed with undifferentiated schizophrenia and mild intellectual disabilities. The resident's electronic medical record (EMR) indicated these diagnoses under the Diagnosis tab, but the Comprehensive Social Assessment V2.0, completed on multiple dates, did not reflect these diagnoses. Each assessment was signed by the Social Service Director (SSD), who noted no history of mental illness in the Mental Development section. Upon inquiry, the SSD stated she was unaware of the resident's diagnoses. The Registered Nurse Resident Assessment Instrument (RAI) Director confirmed that the SSD was expected to review the assessments for accuracy, although the facility did not have a specific policy, relying instead on the RAI manual instructions.
Failure to Conduct Accurate PASRR Screening for Resident
Penalty
Summary
The facility failed to ensure an accurate Level I Preadmission Screening and Resident Review (PASRR) for a resident with a diagnosis of Undifferentiated Schizophrenia and mild intellectual disabilities. Upon review of the resident's electronic medical record (EMR), it was found that the admitting and current diagnosis included these conditions. However, the Comprehensive Social Assessment did not reflect these diagnoses, and the assessments were signed by the Social Services Director (SSD) with a note indicating no history of mental illness. The resident's EMR lacked documentation of a Level I or Level II PASRR. The SSD provided a Level I PASRR completed by the hospital, which inaccurately marked 'No' for the presence of a serious mental illness or intellectual disability. This error resulted in the absence of a Level II screening for specialized services. The SSD admitted to being unaware of the resident's mild intellectual disability diagnosis and stated that the facility followed a document titled 'Best Practice for PASRR' as they did not have a specific policy. The document indicated that PASRR status should be reviewed for all new admissions, and the SSD should maintain an active list of PASRR patients.
Failure to Develop Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a resident, as required by their policy. The policy, reviewed on 12/27/24, mandates the creation of a baseline care plan to ensure person-centered continuity of care and communication with the resident and their representative. The resident in question was admitted to the facility, but a review of their electronic medical record revealed no documented evidence of a baseline care plan. During an interview, the Resident Assessment Instrument Director admitted that the baseline care plan was not developed due to her being on leave, and the responsibility was supposed to be covered remotely by someone from the facility's corporation.
Failure to Update Care Plan for Pain Management
Penalty
Summary
The facility failed to revise the care plan to address pain management for one of the residents, identified as R29. The facility's policy mandates that each patient with identified pain should have a care plan addressing pain management. However, despite R29's complaints of lower back pain and the administration of PRN Tylenol as per a telephone order from the Nurse Practitioner, the care plan did not include any problems, goals, or interventions related to pain. This oversight was confirmed during interviews with the RN, RAI Director, and the Nurse Practitioner, all of whom acknowledged that the care plan should have been updated to reflect the resident's pain issues. The deficiency was further highlighted by the fact that R29 was unable to complete an x-ray due to excessive discomfort, indicating ongoing pain issues. The Medical Director, who was also the resident's attending physician, expressed that it was his expectation that the care plan would have included pain as a problem area following the resident's complaints. The failure to update the care plan placed the resident at risk for ineffective pain management, as the necessary interventions and goals were not documented or implemented.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to consistently implement safety measures for a resident identified as being at high risk for falls. The resident, who has a history of falls, a right below the knee amputation, highly impaired vision, and an unsteady gait, was observed on multiple occasions without the necessary interventions in place. These interventions, as outlined in the resident's care plan, included the use of a low bed and fall mats to prevent injury. Despite these documented needs, the resident was found crawling on the floor on several occasions, including an incident where he sustained a skin tear to his right stump and elbow. Observations revealed that the resident's bed was not in the lowest position, and mats were not placed on the floor as required. The facility's policy on fall management mandates providing residents with adequate supervision and assistive devices to minimize fall risks. However, the resident was left unsupervised in his room, which was located far from the nursing station, and staff were not present to prevent or respond promptly to his attempts to get out of bed or his chair. The Director of Nursing confirmed that the safety measures were not in place as per the care plan, acknowledging that the bed should have been lowered and mats should have been on the floor to prevent such incidents.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to ensure that pain medication was procured and administered as ordered by the physician for one resident, identified as R29. The deficiency was identified when three doses of tramadol, an opioid pain medication, were not available from the pharmacy and thus not administered to the resident. The facility's policy required that when medications are unavailable, the nurse should contact the dispensing pharmacist for further instructions and notify the prescriber. However, this procedure was not followed, leading to the resident experiencing untreated pain. R29 was admitted to the facility with a diagnosis of acute pain due to trauma from a fall. On September 8, 2024, the resident complained of severe lower back pain, which was assessed to be a 10 on a scale of 1-10. The resident was administered PRN acetaminophen, which reduced the pain level to one. On September 10, 2024, the physician ordered tramadol to be administered twice daily for seven days. However, the medication was not delivered on time, and the resident missed three doses on September 10 and 11, 2024. Interviews with facility staff revealed that the pharmacy was waiting for a signed prescription from the physician, which delayed the delivery of tramadol. The Director of Nursing and the Medical Director both stated that the nursing staff should have contacted the pharmacy to use the emergency medication kit, which contained tramadol, and notified the physician for an order. The failure to follow these procedures resulted in the resident experiencing untreated pain and an incomplete x-ray examination due to discomfort.
Failure to Provide Bed Hold Agreement
Penalty
Summary
The facility failed to provide a written bed hold agreement for a resident who was transferred to a behavioral facility for medication stabilization. The resident, who was his own responsible party, had a history of schizophrenia, type 2 diabetes mellitus, hypertension, depression, and gastro-esophageal reflux disease. The resident's cognitive assessment indicated moderate cognitive impairment. Despite these conditions, the facility did not have a signed and acknowledged bed hold agreement explaining the room rates after the Medicaid bed hold expired. The facility's policy on bed holds during hospital stays and therapeutic leaves requires offering residents or their designees the choice to pay to hold the bed or release it. However, during the review of the resident's medical record, it was found that no such agreement was provided or acknowledged by the resident. This oversight was identified during a closed record review and was confirmed through staff interviews, highlighting a lapse in the facility's adherence to its own policy.
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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