Douglasville Center For Nursing And Healing Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Douglasville, Georgia.
- Location
- 4028 Hwy 5, Douglasville, Georgia 30135
- CMS Provider Number
- 115273
- Inspections on file
- 28
- Latest survey
- October 30, 2025
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Douglasville Center For Nursing And Healing Llc during CMS and state inspections, most recent first.
A resident with cognitive impairment and a history of falls experienced a right hip fracture after a fall. Despite X-ray findings indicating a possible fracture and ongoing pain, the resident was not transferred to the hospital until the next day due to unclear emergency transfer procedures and delayed provider response, resulting in the need for surgical intervention.
Two residents were found to have medications at their bedside and were self-administering them without proper assessment or documentation, as required by facility policy. One resident with severe cognitive impairment had IV fluids and heparin flush solution at the bedside without a physician's order or assessment, while another resident with minimal cognitive impairment had multiple medications, including one not prescribed, and was self-administering without a formal assessment. Staff interviews revealed a lack of awareness of the facility's self-administration procedures, and the DON confirmed that no residents had been assessed for self-administration.
Broken wall molding trim was found in three rooms and two broken ceiling tiles were observed in another, with one tile stuffed with a paper towel. The Maintenance Director reported that only two staff were available, no environmental rounds were conducted, and repairs were made only when issues were reported through the TELS system. In one case, a resident's refusal to leave their room prevented repair of damaged wall trim.
The facility allowed a Dietary Manager to continue working after two unsatisfactory criminal background checks, despite policy requiring pre-screening to prevent hiring individuals with a history of abuse, neglect, exploitation, or related offenses. Both the Human Resource Director and Administrators were aware of the unsatisfactory results but permitted the employee to remain in the position.
A resident with dementia and a history of falls was found to have a dislocated shoulder of unknown origin. Although the injury was identified and reported internally, the facility did not report the incident to the State Survey Agency within the required timeframe, as mandated by policy.
A resident admitted with schizophrenia, bipolar disorder, and major depressive disorder did not have a PASRR Level II evaluation submitted, despite facility policy requiring such screening for mental disorder or intellectual disability. Staff confirmed the omission during routine behavior meetings, and record review showed no evidence of the required documentation.
A resident with COPD and other respiratory conditions received oxygen therapy at a rate higher than the physician-ordered 2-4 LPM, as staff administered 5 LPM over several days. An LPN confirmed the discrepancy after reviewing the order, and the DON stated that staff are expected to follow physician orders for O2 administration.
Facility administration did not remove a Dietary Manager with an unsatisfactory criminal background check, including a conviction for aggravated assault, from employment. Despite policy requiring pre-screening for abusive behavior, the Administrator allowed the DM to continue working after being made aware of the background check results, citing the non-direct care role and nature of the conviction.
Staff failed to follow manufacturer and facility protocols for cleaning and disinfecting a glucometer between uses on a resident, with some using only alcohol wipes instead of EPA-registered disinfectant wipes. Interviews revealed inconsistent practices and lack of access to proper disinfectant wipes on at least one medication cart, leading to improper infection control during blood glucose monitoring.
A resident with a history of seizures did not have seizure medication included in their care plan, resulting in a lapse in receiving carbamazepine for several days. The care plan lacked goals or interventions related to seizure management, and staff confirmed the medication was not administered during this period.
A resident with epilepsy did not receive prescribed carbamazepine for several days after a nurse mistakenly discontinued the medication in the MAR. The omission was discovered after the resident exhibited seizure activity, vomiting, and facial drooping, leading to hospital evaluation. Staff and family interviews, along with record review, confirmed the medication error.
A resident with COPD who relied on staff for transfers missed a pulmonology appointment because her personal wheelchair did not fit in the transportation van, and the facility scheduler could not locate a suitable facility wheelchair. The transportation staff did not verify the correct wheelchair or communicate with previous staff, and there was no policy or documentation for arranging such transportation.
A resident with multiple complex medical conditions was not provided with required toileting assistance or timely assessment and treatment for a bleeding leg. The bedside commode was repeatedly left uncleaned, and staff failed to respond to the resident's calls for help, resulting in the resident having to call 911 and document the incident on video. Staff interviews confirmed a lack of clarity regarding responsibilities and no documentation to support that care was provided as required.
The facility did not conduct a thorough investigation after two residents were involved in an incident where one, who had severe dementia and could not consent, was kissed by another resident. The investigation lacked staff and resident interviews, had incomplete documentation, and did not update care plans, failing to meet the requirements of the facility's abuse prevention policy.
A resident who was fully dependent on staff for transfers and required a mechanical lift was injured when a CNA performed a transfer alone, contrary to facility policy and best practices that require two staff to be hands-on. The resident's leg struck the bed frame during the transfer, resulting in swelling and pain. Staff interviews revealed inconsistent understanding of supervision requirements for mechanical lift use, contributing to the incident.
Delay in Hospital Transfer Following Unrecognized Hip Fracture
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral infarction, muscle weakness, difficulty walking, altered mental status, and prior falls suffered a right hip fracture after a fall. The resident was found on the floor, and an X-ray was ordered, which showed a questionable nondisplaced fracture of the right femoral neck. Despite the X-ray findings and the resident's ongoing pain, the resident was not transferred to the hospital until the following day. The facility's Discharge and Transfer Policy did not provide clear guidance on emergency transfers, and staff interviews revealed confusion regarding the appropriate response to such incidents. Nursing staff reported making multiple attempts to contact the physician and nurse practitioner without success, and the resident remained in pain until assessed by the nurse practitioner the next morning. The medical director stated that residents with pain or tenderness after a fall should be sent out immediately, but this did not occur. The delay in recognizing and treating the hip fracture resulted in the resident requiring surgery after eventual transfer to the hospital.
Failure to Assess Residents for Self-Administration of Medication
Penalty
Summary
The facility failed to properly assess and document the ability of two residents to self-administer medications, as required by its own Self-Administration Protocol. For one resident with severe cognitive impairment and a history of IV therapy, IV fluids and heparin lock flush solution were found at the bedside without any physician's order, care plan documentation, or assessment for self-administration. Staff confirmed that the resident was not currently on IV therapy and had not been assessed for self-administration, and the presence of the IV bag at the bedside was not appropriate. For another resident with little to no cognitive impairment, multiple medications, including a nasal spray and a topical gel, were found at the bedside. There was no documentation in the care plan or clinical record of an assessment for self-administration of medication, and one of the medications present was not prescribed in the physician's orders. Staff interviews confirmed that the resident self-administered medication without a formal assessment and that staff were unaware of the facility's procedure for self-administration. The Director of Nursing confirmed that no residents had been assessed for self-administration of medication, despite facility policy requiring such assessments.
Failure to Maintain Clean and Homelike Resident Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean, comfortable, and homelike environment for residents on Unit 30. Specifically, broken wooden wall molding trim was found in three resident rooms, and two broken ceiling tiles were noted in another room, with one tile having a piece of paper towel inserted into the hole. Interviews with the Maintenance Director revealed that only two staff members were assigned to the Maintenance Department, and that environmental rounds were not conducted; instead, maintenance issues were addressed only when reported through the TELS system by nursing staff. Additionally, it was noted that a resident refused to leave their room, which prevented repair of the wall trim behind their bed.
Failure to Remove Employee After Unsatisfactory Background Checks
Penalty
Summary
The facility failed to ensure that staff hiring was preceded by a completed and satisfactory background check, as required by its Abuse Prevention policy. Specifically, the Dietary Manager (DM) was allowed to continue working after two unsatisfactory criminal background checks were received. The policy mandates pre-screening all potential new employees for a history of abusive behavior, but records show that the DM's background checks, dated 11/21/2022 and 2/11/2025, both returned unsatisfactory results. Interviews with the Human Resource Director (HRD) and Administrator revealed that the first unsatisfactory background check was brought to the attention of the previous Administrator, who approved the DM to continue working. The HRD was aware of the unsatisfactory status and, after the DM was promoted, requested an appeal, which also resulted in an unsatisfactory finding. Despite this, the DM was allowed to remain employed after the HRD informed the current Administrator and consulted with Regional Human Resources, who again approved continued employment.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident within the required timeframe to the State Survey Agency (SSA), as mandated by facility policy. The resident, who had diagnoses including Alzheimer's disease, dementia, cerebral ischemia, and a history of falls, was observed by a Restorative Aide to be favoring his left shoulder. The aide noticed a knot below the resident's shoulder and reported it to the Unit Manager immediately. Subsequent medical evaluation, including an x-ray and orthopedic consultation, led to a diagnosis of a dislocated left shoulder, and the resident was sent to the emergency department for treatment. Staff interviews and record reviews indicated that no recent falls or incidents were reported, and the origin of the injury could not be determined. Despite the facility's policy requiring immediate reporting of such incidents, the injury was not reported to the SSA within the required timeframe. Documentation showed that the injury was first observed and reported internally, but the formal Facility Incident Report was not submitted to the SSA until later. The delay in external reporting constituted a failure to comply with abuse prevention and reporting protocols, as outlined in the facility's own policy and federal regulations.
Failure to Submit PASRR Level II for Resident with Mental Illness Diagnosis
Penalty
Summary
The facility failed to submit a PASRR Level II evaluation for a resident who was admitted with diagnoses including schizophrenia, bipolar disorder, and major depressive disorder. According to the facility's policy, all residents with mental disorder (MD) or intellectual disability (ID) diagnoses are to be screened prior to admission and referred for a Level II evaluation if indicated, including upon a significant change in status. Review of the electronic medical record and paper medical records revealed no evidence that a PASRR Level II was completed or submitted for this resident, despite qualifying diagnoses. Staff interviews confirmed that the Social Services department holds weekly behavior meetings to discuss new admissions, diagnoses, and resident behaviors. During these meetings, the resident's qualifying diagnoses were discussed, but the necessary PASRR Level II documentation was not submitted. The Minimum Data Set (MDS) indicated the resident was not considered by the state PASRR process to have a serious mental illness or related condition, despite active diagnoses of schizophrenia and no psychological services being documented.
Failure to Administer Oxygen Therapy per Physician Order
Penalty
Summary
Staff failed to deliver oxygen therapy according to the physician's order for a resident with chronic obstructive pulmonary disease (COPD), cough, and pleural effusion. The physician's order specified continuous humidified oxygen at 2-4 liters per minute (LPM) via nasal cannula. However, multiple observations over three consecutive days showed the resident receiving oxygen at 5 LPM, which exceeded the ordered range. During an interview, an LPN confirmed that the oxygen concentrator was set to 5 LPM and acknowledged the discrepancy after reviewing the physician's order. The Director of Nursing stated that nurses are expected to follow physician orders for oxygen administration and that any changes require a new order and family notification. The failure to adhere to the prescribed oxygen flow rate constituted the deficiency.
Failure to Remove Employee with Unsatisfactory Background Check
Penalty
Summary
Facility administration failed to provide adequate oversight to ensure that an employee, specifically the Dietary Manager (DM), was free from adverse action on their criminal background check while employed. Review of the facility's Abuse Prevention policy indicated that all potential employees must be pre-screened for a history of abusive behavior. However, records showed that the DM had two unsatisfactory Georgia Background Checks, with a conviction for aggravated assault. Despite being aware of the unsatisfactory background check, the Administrator allowed the DM to continue working, reasoning that the DM was not in a direct care role and that the conviction did not constitute a domestic offense. This inaction was confirmed through interviews with both the Human Resource Director and the Administrator.
Failure to Properly Disinfect Glucometer Between Resident Uses
Penalty
Summary
The facility failed to ensure proper cleaning and disinfection of a glucometer during routine fasting blood sugar checks for one resident. Observations revealed that a Certified Medication Aide (CMA) used alcohol wipes, rather than an EPA-registered disinfectant, to clean the glucometer after use. Interviews with additional staff confirmed that alcohol wipes were being used on at least one medication cart, and that EPA-registered disinfectant wipes were not available on that cart. Manufacturer instructions for the Assure Platinum blood glucose monitoring system specify that the meter should be cleaned and disinfected between patient use with an EPA-registered disinfectant wipe, and that alcohol wipes alone are not sufficient. Further interviews with staff, including another CMA, an LPN, the Infection Preventionist, and the Director of Nursing, revealed inconsistent practices and understanding regarding the proper cleaning protocol for glucometers. While some staff described using the correct germicidal wipes and alternating between two glucometers to allow for proper drying time, others continued to use alcohol wipes or lacked access to the appropriate disinfectant wipes. This inconsistent adherence to infection prevention protocols resulted in a failure to properly disinfect the glucometer between uses, as required by manufacturer guidelines and facility policy.
Failure to Include Seizure Medication in Care Plan
Penalty
Summary
The facility failed to include seizure medication in the care plan for one resident, resulting in the omission of a care plan goal related to the resident's seizures. Record review showed that the resident had a medication order for carbamazepine suspension to be administered via PEG-tube every 12 hours for seizure prophylaxis, with a discontinuation and subsequent restart of the medication. The Medication Administration Record indicated that the resident did not receive carbamazepine for a period between discontinuation and restart. Interviews with the Administrator and Nurse Practitioner confirmed that the resident was without her seizure medication for several days, and the care plan did not address her seizure management needs.
Failure to Administer Prescribed Seizure Medication Due to MAR Error
Penalty
Summary
A medication error occurred when a nurse at the facility failed to properly transfer and administer a prescribed seizure medication, carbamazepine, for a resident with a history of epilepsy and other medical conditions. The medication was mistakenly discontinued in the Medication Administration Record (MAR), resulting in the resident not receiving the seizure medication for several days. Documentation and interviews confirmed that the medication was not given from the time it was discontinued until it was reordered and resumed, leaving a gap in administration. During this period, the resident experienced symptoms including projectile vomiting, seizure activity, facial drooping, and unresponsiveness, which prompted staff to notify the nurse practitioner and the resident's responsible party. The resident was subsequently sent to the emergency room for evaluation and treatment. Interviews with staff and family members confirmed that the omission of the seizure medication was discovered after the resident exhibited these symptoms, and a review of the MAR verified the lapse in medication administration.
Failure to Accommodate Resident's Transportation Needs for Medical Appointment
Penalty
Summary
A resident with chronic obstructive pulmonary disease (COPD) and intact cognition, who was dependent on staff for toileting and transfers, missed a scheduled pulmonology appointment due to issues with transportation arrangements. The resident reported that her personal wheelchair did not fit in the transportation van, and although a facility wheelchair that would fit was available, the scheduler was unable to locate it for her use. The resident remained in her room, and the facility wheelchair was later found stored in the facility's bus. The newly assigned transportation staff member was informed by the resident about the wheelchair issue the day before the appointment. The staff member contacted the transportation company and received confirmation that a wheelchair would fit, but mistakenly assumed the resident's personal wheelchair was suitable. The staff member did not communicate with the previous scheduler, who had knowledge of the appropriate facility wheelchair. Additionally, there was no facility policy for scheduling or arranging transportation for outside appointments, and the transportation staff member did not have documentation of her communications regarding the incident.
Failure to Provide Toileting Assistance and Timely Wound Care
Penalty
Summary
The facility failed to provide necessary toileting assistance and timely assessment and treatment for a bleeding right leg to one resident. The resident, who had diagnoses including end-stage renal disease, dependence on dialysis, diabetes mellitus, and an infection of an amputated left lower limb, required substantial assistance for toileting as documented in the care plan. Observations revealed that the resident's bedside commode was repeatedly left uncleaned, with dried bowel movements present, and staff interviews confirmed that cleaning and toileting assistance were not consistently provided as required. The resident reported not being assisted to the bedside commode and that staff did not respond to call lights, leading him to call 911 for help. He also documented an incident on his cell phone where he was left with a bleeding right leg, and staff failed to provide assessment, wound care, or notify a physician. The resident expressed emotional distress, stating he had to scream and beg for help, and that his concerns were communicated to his family and the APRN. Staff interviews revealed confusion and lack of clarity regarding responsibilities for toileting assistance and cleaning the commode. The LPN on duty did not assess or treat the bleeding leg and did not notify the physician. The CNA assigned to the resident admitted to not cleaning the commode after use. There was no documentation to validate that toileting assistance was provided as per the care plan, and the DNS confirmed the absence of a policy for nursing standards of care and lack of documentation for these services.
Failure to Thoroughly Investigate Alleged Sexual Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual abuse involving two residents, one with severe dementia and the other with no cognitive impairment. The incident involved one resident being observed kissing another resident, who was unable to consent due to cognitive status. The facility's Abuse Prevention policy required immediate investigation and protection of alleged victims, but the investigation lacked key elements. Specifically, the documentation provided by the facility did not include statements from other staff members regarding the residents' interactions, nor did it show that other residents who could respond were interviewed to determine if they had witnessed or experienced similar incidents. The incident report form was incomplete, missing answers to critical questions such as whether there was an injury, if treatment was required, and the location of the incident. The only witness statement was from the DON and did not fully describe the observed event. Interviews with facility staff confirmed that no additional residents or staff were interviewed as part of the investigation. The care plans for the involved residents were not updated following the incident, and the administrator stated that they did not see the need for such updates. The facility concluded that the suspected sexual abuse allegation could not be substantiated due to unclear motivation, but the investigation did not meet the requirements outlined in the facility's own policy.
Failure to Provide Adequate Supervision During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a resident who was totally dependent on staff for transfers and required the use of a mechanical lift was not provided with adequate supervision and assistance during a transfer. The resident, who had multiple diagnoses including bipolar disorder, diabetes, and impaired mobility, was being transferred from bed to chair using a mechanical lift by a CNA. The care plan did not specify the number of staff required for safe transfers, and the physical therapy evaluation only indicated the need for a Hoyer lift without detailing staffing requirements. During the transfer, the CNA performed the task alone, despite facility policy and best practices indicating that two staff members should be hands-on during the use of a mechanical lift to ensure resident safety. The CNA had informed an LPN of the intention to transfer the resident, and the LPN stated they were on standby in a nearby room but not present in the room during the transfer. As a result, the resident's lower extremity struck the frame of the bed, causing a painful swelling. The incident was documented, and an x-ray was performed, which was negative for fracture. Interviews with staff revealed inconsistent understanding and implementation of the facility's policy regarding mechanical lift transfers. The Director of Rehab confirmed that two staff should be hands-on during such transfers to prevent accidents, while the Director of Nursing stated that one staff could operate the lift with another on standby nearby. This lack of clear guidance and adherence to safe transfer protocols directly contributed to the resident sustaining an injury during the transfer.
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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