Delmar Gardens Of Gwinnett
Inspection history, citations, penalties and survey trends for this long-term care facility in Lawrenceville, Georgia.
- Location
- 3100 Club Drive, Lawrenceville, Georgia 30044
- CMS Provider Number
- 115350
- Inspections on file
- 14
- Latest survey
- August 14, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Delmar Gardens Of Gwinnett during CMS and state inspections, most recent first.
The facility failed to properly date and label opened food items in the cooler, freezer, and dry food pantry, and did not maintain cleanliness in the kitchen. Observations revealed undated food items, a dirty oven and ice machine, and a utility worker not wearing a hairnet. Staff interviews indicated inconsistencies in labeling and dating food items, with some staff unsure about the process. The Chef and Dietary Manager were unable to read codes on food containers, leading to expired items being stored.
The facility failed to ensure one of two dumpsters had a plug in place and that the surrounding area was free of trash and debris. Trash, including soiled diapers, was observed on the ground behind the dumpster. The Dietary Manager and Maintenance Director confirmed the issue, and the Administrator indicated that staff should have a system in place to address such problems.
The facility failed to ensure the flat top oven in the kitchen was working properly, affecting all 58 residents who received an oral diet. The oven door was broken, and no maintenance work order was submitted for repair. Kitchen staff used the broken oven for storage, and the issue was verbally reported but not documented, leading to the deficiency.
The facility failed to ensure a Level II PASARR was conducted for a resident following a mental illness diagnosis. The resident's care plan noted the use of antipsychotic and antidepressant medications, but the Level I PASARR assessment did not indicate any mental illness, and thus, a Level II evaluation was not triggered. Interviews revealed that there was no process in place to review the Level I PASARR for accuracy.
The facility failed to follow individualized care plans for monitoring side effects of anticoagulant drug use for two residents. Despite having care plans that included monitoring for adverse effects such as abnormal bruising or bleeding, the facility did not adhere to these plans.
The facility failed to provide adequate vision and hearing care for three residents, including those with macular degeneration and diabetes. Despite residents expressing concerns and the facility's policy on maintaining hearing and vision abilities, there were no documented care plans, and the facility did not offer in-house optometry services.
The facility failed to document monitoring and side effects of anticoagulant use for two residents receiving Coumadin and Eliquis. Staff interviews revealed a lack of awareness and understanding of the need to monitor for side effects, and the monitoring orders were not entered into the system, resulting in no documentation on the MAR.
The facility failed to ensure medications were dated appropriately when opened and to discard expired medical supplies in one of three medication carts. Observations revealed multiple medications without open or discard dates, and expired oral supplements were found in the storage room. Staff interviews indicated awareness of the requirements but inconsistent adherence to procedures.
Failure to Properly Date and Label Food Items and Maintain Cleanliness in Kitchen
Penalty
Summary
The facility failed to ensure that opened food items were properly dated and labeled in the cooler, freezer, and dry food pantry. During a tour of the kitchen, several food items, including slider buns, lentils, spinach, okra, and corn flakes, were found without open dates. Additionally, the oven flat top was dirty with old grease and food, and the ice machine filters and the area around the opening were also dirty. Furthermore, a utility worker was observed not wearing a hairnet, and the recipe for pureed food was not followed as the thickening agent was not measured. Interviews with staff revealed inconsistencies in labeling and dating food items, with some staff unsure about the process and others discarding undated food items. The Chef admitted to not knowing how to read certain codes on food containers, leading to expired items being stored in the pantry. The facility's policies on food storage and labeling were not adhered to, as evidenced by the observations and staff interviews. The Chef and Dietary Manager were unable to read the codes on several food containers, resulting in expired items being kept in the pantry. The Administrator acknowledged that there should be systems in place and that staff should be educated on labeling procedures. Despite the presence of a representative providing information on how to read the codes, the Dietary Manager and Chef still could not determine the expiration dates of several items. This deficiency had the potential to affect all 58 residents who received an oral diet from the kitchen.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure one of two dumpsters had a plug in place and that the surrounding area around the dumpster was free of trash and debris. During an observation, it was revealed that the dumpster on the left side was unplugged and did not have a cap on it. Additionally, trash, including soiled diapers, was observed on the ground behind the dumpster. The Dietary Manager began to pick up the trash and put it in the dumpster. The Maintenance Director confirmed that the dumpster on the left side was unplugged and did not have a cap, stating that the opening was sealed and the drain was inside the dumpster. The Administrator indicated that staff should have a system in place to address such problems and that this issue should be taken to the Quality Assurance meeting.
Failure to Maintain Essential Kitchen Equipment
Penalty
Summary
The facility failed to ensure the flat top oven in the kitchen was working properly, specifically that the oven door would close efficiently to prepare cooked meals. This issue had the potential to affect all 58 residents who received an oral diet from the kitchen. The Nursing Home Maintenance work orders from 2/14/2024 through 4/13/2024 revealed no order to repair the oven. During a kitchen tour and interview with the Chef on 4/13/2024, it was observed that the oven was not clean and had a towel pushed between the door and stove to keep it closed. The Chef admitted the door was broken and had verbally informed the Maintenance Director (MD) about it. However, no written work order was submitted for the repair. The MD confirmed that he fixed the oven door and stated that staff should complete a maintenance work order for broken equipment, but he did not receive any written request for this issue. The Administrator expected staff to have a system in place to address such problems and mentioned that this process should be discussed in the Quality Assurance (QA) meeting. Interviews with kitchen staff revealed that the flat top stove had been broken for a couple of weeks. Cook GG and Cook HH both confirmed the stove's condition and mentioned that it was used for storage during this period. The Chef admitted to not filling out a work order for the broken oven door but had verbally informed the MD. This lack of proper documentation and follow-through led to the deficiency in ensuring the essential kitchen equipment was functioning correctly, potentially impacting the quality of meals prepared for the residents.
Failure to Conduct Level II PASARR for Resident with Mental Illness Diagnosis
Penalty
Summary
The facility failed to ensure a Level II PASARR was conducted for a resident (R21) following a mental illness diagnosis. The resident was readmitted to the facility with diagnoses including generalized anxiety disorder and depression. The facility's policy mandates that all residents receive a Pre-Admission Screening and Resident Review (PASARR) in accordance with state and federal regulations. However, the review of R21's records revealed that the Level I PASARR assessment did not indicate any mental illness, and thus, a Level II evaluation was not triggered. The resident's care plan noted the use of antipsychotic and antidepressant medications, which should have prompted further review for a Level II PASARR evaluation. Interviews with the Social Service Director (SSD) and the facility's Administrator revealed that the Level I PASARR was completed by the hospital prior to admission, and the previous admission director did not select the diagnoses of anxiety and depression on the application. The SSD confirmed that there was no process in place to review the Level I PASARR for accuracy. Consequently, the facility was unable to ensure that a Level II PASARR was not required, leading to a failure in compliance with the PASARR program requirements.
Failure to Follow Care Plans for Anticoagulant Monitoring
Penalty
Summary
The facility failed to follow the individualized care plan for monitoring side effects of anticoagulant drug use for two residents. Resident 27, who has diagnoses including deep vein thromboses and atrial fibrillation, was prescribed Coumadin. The care plan for Resident 27 included monitoring for adverse effects such as abnormal bruising or bleeding and observing stools for blood. However, the facility did not adhere to this care plan. Similarly, Resident 31, diagnosed with atrial fibrillation and anxiety, was prescribed Eliquis. The care plan for Resident 31 also included monitoring for signs of abnormal bruising or bleeding and observing stools for blood, but this was not followed either. Interviews with the Minimum Data Set (MDS) Nurse and the Director of Nursing (DON) revealed that the care plans are generated from MDS assessments and are expected to be followed by all staff. The MDS Nurse confirmed that she is responsible for ensuring the accuracy of assessments and the development of care plans reflecting the residents' current status. The DON stated that it is her expectation that residents on anticoagulant medications should have a care plan for monitoring side effects and that all staff should follow these care plans. Despite these expectations, the facility did not follow the care plans for monitoring the side effects of anticoagulant medications for the two residents in question.
Failure to Provide Adequate Vision and Hearing Care
Penalty
Summary
The facility failed to provide adequate assistance and support from social services for three residents (R21, R30, and R7) in receiving vision care. R21, who had macular degeneration and was almost blind, had not had an eye exam in two years and also reported difficulty hearing. Despite these issues, there was no documented vision or hearing care plan for R21. Similarly, R30, a diabetic resident, had not seen an optometrist in two years and expressed concerns about his vision. He mentioned that it was difficult to go out for appointments and had never been offered in-house optometry services. R7, another diabetic resident, also reported not having her vision checked in a while despite wearing glasses and recognizing the need for regular vision checks due to her condition. Interviews with the Social Service Director (SSD) and the Administrator revealed that the facility did not have an optometrist visiting the facility and relied on outside services for vision care. The SSD was unaware that vision services could be provided in-house, and the Administrator admitted to a lack of knowledge regarding the provision of in-house vision services. The MDS Coordinator, responsible for assessing residents' vision, stated that any complaints about vision would be reported to the Director of Nursing and the physician, but this process did not seem to be effectively addressing the residents' needs. The facility's policy on maintaining hearing and vision abilities indicated that residents should receive proper treatment and assistive devices, but this was not being implemented effectively. The failure to provide necessary vision and hearing care for these residents has the potential to affect their quality of life, as evidenced by the residents' expressed concerns and the lack of documented care plans addressing these issues.
Failure to Monitor Anticoagulant Use
Penalty
Summary
The facility failed to document monitoring and side effects of anticoagulant use for two residents, R27 and R31, who were receiving Coumadin and Eliquis, respectively. R27, with diagnoses including deep vein thrombosis, congestive heart failure, and atrial fibrillation, had no documented monitoring for anticoagulant use from April 1 through April 16, 2024. Similarly, R31, with diagnoses including atrial fibrillation and congestive heart failure, also had no documented monitoring for anticoagulant use during the same period. The facility's policy required licensed nurses to chart all pertinent information related to Coumadin administration, including signs and symptoms of hemorrhagic adverse effects, but this was not followed for these residents. Interviews with staff revealed a lack of awareness and understanding of the need to monitor residents on anticoagulants for side effects. LPN MM stated that medication techs should be monitoring residents' behaviors and side effects of anticoagulants, but this was not being done. CNA/CMA LL and LPN NN both indicated they were unaware of the need to monitor for signs of bleeding or bruising, as it was not on the medication record. The MDS Nurse and the DON confirmed that the monitoring orders were not entered into the system, and thus, the monitoring was not documented on the MAR for R27 and R31.
Failure to Date and Discard Medications Appropriately
Penalty
Summary
The facility failed to ensure medications were dated appropriately when opened to determine the discard date, and also failed to discard expired medical supplies in one of three medication carts. During an observation of medication administration, it was found that a Symbicort inhaler and a bottle of artificial tears were not labeled with an open or discard date. The Certified Medication Aide (CMA) responsible for the cart stated she did not know who had opened the medications and did not pay attention to the dates on the bottles. Additionally, a medication cart check revealed a vial of Levemir insulin and a bottle of fluticasone propionate without open or discard dates, and a bottle of Magnesium Citrate with a broken seal. Another cart check found olopatadine eye drops with an open date that exceeded the manufacturer's discard instructions and a Kardex of hydrocodone tablets for a discharged resident still in the cart's narcotic box. The Director of Nursing (DON) acknowledged the issues and stated that the Central Supply clerk was on leave, which contributed to the oversight of expired oral supplements in the storage room. The DON also mentioned that the pharmacy consultant nurse conducts quarterly audits and provides in-service training to address these issues, but the problems persisted. The facility's policies on expiration dating of medications and medications with shortened expiration dates were not followed, as evidenced by multiple medications not being labeled with open dates. The Pharmacy Nurse Consultant's report confirmed that the medication carts had several medications, including inhalers, nasal sprays, and insulin vials/pens, which were not labeled with an open date. The consultant nurse also noted that the facility had a history of similar issues and had provided in-service training to staff, but the deficiencies continued to occur. Interviews with staff members revealed that they were aware of the requirement to date medications when opened but failed to consistently follow this procedure. The Director of Nursing (DON) and the Infection Preventionist found expired oral supplements in the medication storage room, which were discarded immediately. The DON admitted to missing the expiration dates due to the absence of the Central Supply clerk and stated that she would check all the bottles of the supplement on the medication carts to ensure they were not expired. The Pharmacy Nurse Consultant confirmed that she visits the facility approximately every eight to ten weeks to conduct cart audits and provide written reports for in-service training. Despite these efforts, the facility continued to have issues with expired medications and medications not being labeled with open dates, leading to the identified deficiencies.
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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