Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Douglasville Center For Nursing And Healing Llc during CMS and state inspections, most recent first.
Unsanitary areas, unsecured oxygen tanks, dirty IV stands, and leaking HVAC units were observed throughout the facility. The laundry room had debris on the floor, missing tiles, water damage, and a sink with stagnant water; the shower room had stained grout; empty O2 tanks were left unsecured outside the storage cage; two residents receiving enteral feedings had metal IV stands and bases with dried brown residue; and leaking AC/heating units in two rooms had basins placed underneath them. The DON and Maintenance Director confirmed several of these conditions.
Failure to protect resident privacy and confidentiality occurred when tracheostomy care was provided to two cognitively intact residents with the room door open and the privacy curtain not drawn, allowing the treatments to be visible. The facility also mistakenly mailed a room change notice containing another resident's name to an unauthorized family member, and the DON/Administrator confirmed the error.
Failure to timely report a resident-to-resident abuse allegation. A resident with moderate cognitive impairment reported that another resident with dementia made an inappropriate sexual comment in the lobby area, and the resident said no physical sexual act occurred. The resident told staff the same evening, but police were not contacted until the next day after the resident reported it herself, and the SA report was submitted later that day. The facility policy required immediate reporting, but not later than 2 hours, for abuse allegations.
A facility failed to complete a thorough investigation of an allegation of sexual abuse between two residents. One resident with depression, altered mental status, and moderate cognitive impairment reported that another resident made inappropriate sexual comments, but the investigation did not include key staff interviews, a detailed interview of the alleged victim, witness interviews, or review of whether other female residents had similar concerns. The Administrator stated the investigation was vague and lacked needed details and documentation.
Inaccurate MDS Coding for Resident Fall: A resident with dementia and behavioral disturbances had a quarterly MDS that did not include a documented unwitnessed fall with bruising and a laceration, even though the event occurred during the assessment period. The MDSC confirmed the fall should have been included, and the DON stated the MDS was to be accurate.
Failure to Provide Timely ADL Care, Bathing, and Personal Hygiene: The facility failed to provide timely incontinence care for one resident who was dependent for toileting, failed to ensure bathing/showering occurred as documented for three residents who were dependent for bathing, and failed to provide shaving and nail care for a totally dependent resident. Observations, resident interviews, record review, and staff statements showed delayed incontinence care, sparse or missing bath/shower documentation, and a resident left unshaven with overgrown fingernails.
Meals were not consistently served within scheduled meal times. Residents and staff reported that breakfast, lunch, and dinner were often late, with some meals delayed 30 minutes or more. On the secured unit, lunch trays were observed being delivered late, and the RD confirmed the delay. The DM said the dietary department had been short three aides since January, which contributed to late trays. Residents who needed feeding assistance, including a resident with Devic disease and another with cerebral infarction, were also observed receiving lunch after the scheduled time.
The facility failed to follow infection control practices during trach care, EBP care, perineal care, catheter maintenance, and handling of soiled items. A RT did not change gown or mask between two residents receiving trach care, staff entered a resident’s room on EBP without the required gown, a CNA did not change gloves or perform hand hygiene between contaminated and clean tasks during incontinent care, and a resident’s catheter bag was observed on the floor. Staff also found a cracked shower cushion and soiled bags left on the shower room floor.
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.
Unsanitary areas, unsecured oxygen tanks, dirty IV stands, and leaking HVAC units
Penalty
Summary
The facility failed to maintain the laundry services area in a clean, sanitary, and safe condition. During an observation of the clean side of the laundry room, several resident slippers, a gray plastic wash basin, dried soap residue, and a pressure reduction bootie were seen on the floor beneath the industrial washing machines. Tiles were missing beneath the right-side washing machine, an uncovered drain contained rusty water, and the wall behind the utility sinks showed significant water damage with staining and an open, deteriorated area. One utility sink contained stagnant water that was not draining, and a stack of mechanical lift slings was observed on the floor outside the clean area. The EVSD stated night shift staff were responsible for gathering these items and that it was not being completed. The [NAME] shower room was also observed to have unsanitary conditions. In one shower stall, a heavy black substance was seen on the grout lines on the left side, and yellow/pinkish staining was seen on the grout lines on the right side. The Maintenance Director stated he was not aware that the grout required replacement and reported that the issue had not been entered into TELS. The facility also had unsecured empty oxygen tanks stored outside beneath the walkway connecting the facility to the laundry room. The empty tank cage was completely full, and 19 empty oxygen tanks were found outside the cage, unsecured and not labeled to indicate they were empty. The Corporate Director of Respiratory confirmed the tanks were not secured and were unsafe. The facility also failed to maintain metal IV stands in a clean and sanitary condition for two residents receiving enteral feedings. R22 and R13 were repeatedly observed in bed with a metal IV stand beside them holding a container of brown-colored enteral formula. On multiple observations, the IV stand and base were unclean with accumulated dried brown residue consistent with spilled formula. The DON confirmed the stands and bases were unclean and stated nursing staff should clean the IV stand when formula is spilled to prevent drying, and that housekeeping or maintenance would need to remove dried substances if the formula had already dried. In addition, leaking air conditioning/heating units beneath the windows in two rooms were observed on multiple occasions with basins containing clear liquid placed on the floor, and one observation included a blanket beneath a basin. The Maintenance Director confirmed the units were leaking.
Failure to Protect Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to keep residents' personal and medical records private and confidential when respiratory treatments were performed in public view without privacy measures. R34 was admitted with paraplegia, acute and chronic respiratory failure, and tracheostomy status, and had a BIMS score of 12 out of 15 indicating cognitive intactness. R235 was admitted with chronic respiratory failure and tracheostomy, and had a BIMS score of 15 out of 15 indicating cognitive intactness. During observation, a Respiratory Therapist provided tracheostomy care to R235 with the room door open and the privacy curtain not drawn, then moved to R34 and performed tracheostomy care without closing the curtain between the two residents and without closing the room door. The facility also failed to protect R132's confidentiality when a 15-day room change notice letter containing R132's name was mistakenly mailed to another resident's family member. R132 was admitted with chronic respiratory failure, gastrointestinal hemorrhage, and functional quadriplegia, and was assessed as being in a persistent vegetative state with no BIMS interview conducted. R132's responsible party reported concern that the resident's name appeared in the letter sent to the other resident's family member, and the Administrator confirmed the facility had mistakenly sent the notice containing R132's name to that individual.
Failure to Timely Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to implement its abuse reporting policy for a resident-to-resident allegation involving two cognitively impaired residents. R53, who had diagnoses including depression, altered mental status-unspecified, and cognitive communication deficit, had a BIMS score of 12 and reported that R30 approached her in the admission lobby area and made an inappropriate sexual comment. R30, who had diagnoses of dementia and other signs and symptoms involving cognitive function and awareness, had a BIMS score of 9. The incident report documented that R53 said no physical sexual act occurred and that R30 denied making the comment. The record showed that R53 told staff about the incident on the evening of 03/07/2026, but police were not contacted until 03/08/2026 at approximately 11:30 AM after R53 reported the matter herself. The facility submitted the allegation to the State Agency on 03/08/2026 at 5:05 PM, and the investigative documentation later stated that R30 was placed on one-to-one supervision, redirected from R53's unit, and the resident representative was notified. The facility policy required reporting all alleged violations to the Administrator, State Agency, adult protective services, and other required agencies within the required timeframes, including immediately but not later than 2 hours after the allegation is made when abuse is involved or serious bodily injury results.
Incomplete Investigation of Sexual Abuse Allegation
Penalty
Summary
The facility failed to complete a thorough investigation of an allegation of sexual abuse involving one resident and another resident. The allegation began when the resident reported that the other resident made an inappropriate sexual comment while she was sitting in the admission lobby area off the unit. The incident report documented that the resident said no physical sexual act occurred and that the other resident denied making inappropriate comments. A progress note later stated that police arrived after being contacted by the resident, who reported that the other resident made inappropriate sexual comments and that she had told a staff member on the unit, who said she would speak with the resident. The resident involved had diagnoses of depression, altered mental status-unspecified, and cognitive communication deficit, and her MDS showed a BIMS score of 12, indicating moderate cognitive impairment. The facility’s five-day summary to the State Survey Agency stated that staff became aware of the allegation after local law enforcement arrived, but the investigation did not include interviews of staff who worked that night, an interview of the resident for details of what was allegedly said, additional resident interviews for witnesses, or inquiry into whether other female residents had been subjected to sexual comments. During interview, the Administrator stated the investigation was vague and identified missing interviews and documentation, including staff, CNA, housekeeper, interviewable residents, and the psychiatric note. The facility policy required interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others with knowledge of the allegation, and required complete and thorough documentation.
Inaccurate MDS Coding for Resident Fall
Penalty
Summary
R233, who was admitted with a diagnosis of dementia with behavioral disturbances, had a quarterly MDS assessment with an ARD of 02/10/2026 that was not accurately coded. Facility records showed the resident sustained an unwitnessed fall on 01/02/2026 with bruising of the upper left arm and a laceration of the left eye, but the MDS contained no documentation that the fall occurred during the assessment period. The assessment also indicated staff were unable to determine a BIMS score. During interview, the MDSC stated she gathers resident-specific data through visual assessment and review of clinical documentation and reports, and confirmed that R233's fall was not included in the quarterly MDS even though it should have been. The DON stated that the MDS was to be accurate. The RAI Manual states that information used for the assessment should cover the same observation period as the MDS items and be validated for accuracy by the IDT completing the assessment.
Failure to Provide Timely ADL Care, Bathing, and Personal Hygiene
Penalty
Summary
The facility failed to provide timely ADL care for five sampled residents. For one resident who was dependent for toileting and cognitively intact, staff did not provide timely incontinence care during the night shift. The resident told the surveyor she had been wet since night shift, had incontinence briefs, and her call light did not work, so she used a bell at bedside. She stated staff ignored the bell and said they would clean her up after breakfast. The resident was observed ringing the bell several times without response, and later a CNA completed care and found the brief contained feces and excess, dripping urine. The facility’s documentation for incontinence care was blank for the prior night, and the DON confirmed the expectation was that residents be changed in a timely manner, at least within 30 minutes, with rounding every two hours. Three residents did not receive bathing or showering as documented or expected. One resident, who was dependent for showers/bathing and cognitively intact, had documentation showing only three baths or showers over a three-month period, with no documentation for several months. Facility leadership stated bathing/showers were not documented in the EMR and that they did not have bath aides, while CNAs had assigned residents and restorative staff assisted. Another resident, who was dependent on staff for all ADLs and had a care plan identifying an ADL self-care deficit, had bed bath documentation only on three dates over several weeks. The resident stated the bed baths were not routine, and the Administrator confirmed there were no more bed/shower records for that resident. A third resident, who required partial/moderate assistance with bathing, had shower documentation showing only one shower during each of two weekly periods when the DON confirmed the resident should have received two. One resident who was totally dependent on staff for personal hygiene was observed twice unshaven with fingernails uneven and varying in length, with several nails about one-half inch past the fingertips. CNA and LPN interviews confirmed the resident was dependent for ADL hygiene and needed shaving and nail trimming. The CNA stated the resident usually received a bed bath and that the last shave had been two weeks earlier. The LPN stated residents received bed baths two to three times per week and should be shaved at least weekly, with nail care done by CNAs when the resident got a shower. The Administrator and DON confirmed that personal hygiene, including shaving and nail care, should be provided every day and that a dependent resident should not be left unshaven or with fingernails in varied length or extending one-half inch past the fingertips.
Meals Served Late and Outside Scheduled Times
Penalty
Summary
Meals and snacks were not served at times in accordance with resident needs, preferences, and requests. Review of the Monthly Resident Council Meeting Minutes showed that residents had already voiced concern that meals were being served late. During a resident group interview, six residents who were identified by the facility as reliable historians and alert and oriented stated that meals were frequently served 30 minutes or more late and that this could happen with any meal. One resident reported that meals were sometimes late because nursing assistants did not deliver them in a timely manner and sometimes because the kitchen did not have enough staff, especially on weekends. Observations on the secured unit showed lunch trays being served late to residents in their rooms, including one resident who was the last resident on the unit to receive lunch at 2:26 PM. The Registered Dietitian confirmed that lunch meals on the secured unit were served late and stated she did not know why they were later than scheduled. The Dietary Manager stated the dietary department had been short three dietary aides since January, that staff tried to stick to the schedule, and that if breakfast was late then lunch was late because the department was short-staffed. The deficiency also affected residents who required assistance with eating. One resident with Devic disease, bilateral upper and lower extremity impairments, and dependence on staff for all ADLs was observed beginning the noon meal at 2:35 PM and finishing at 2:55 PM, and later stated that lunch and dinner were served after their scheduled times. Another resident with cerebral infarction and dependence on staff for eating was observed receiving lunch assistance at 2:19 PM. A cognitively intact resident with spinal stenosis stated that lunch was served after 2:00 PM on one day and at about 12:30 PM on other days. The facility’s documented meal start times listed breakfast from 7:00 AM to 8:45 AM, lunch from 12:00 PM to 1:45 PM, and dinner from 5:00 PM to 6:45 PM.
Infection control failures during resident care and equipment handling
Penalty
Summary
The facility failed to ensure proper infection control practices during resident care and handling of equipment and supplies. During tracheostomy care, a respiratory therapist provided care to one resident with tracheostomy status and then moved to another resident in the same room without removing or changing the gown or mask, even though both residents were on Enhanced Barrier Precautions (EBP). The therapist removed gloves, sanitized hands, and put on clean gloves between residents, but did not change the gown or face mask. The therapist stated she did not need to change the gown or mask because the residents were in the same room. The Administrator and DON later confirmed that PPE should be changed between residents to prevent cross contamination. The facility also failed to ensure staff used PPE correctly during care for another resident on EBP. A CNA and the Staffing Coordinator entered the resident’s room, where an EBP sign instructed staff to don a gown and gloves. Both staff came out wearing gloves but no gown after rolling the resident and checking the brief. They stated they were unaware that a gown was required before working with the resident. In another observation, a CNA provided incontinent care to a resident who was dependent on staff for toileting hygiene, removed the soiled brief, cleaned the resident, applied a clean brief, repositioned the resident, and adjusted the bedding without changing gloves or performing hand hygiene between the contaminated and clean tasks. The CNA stated she sanitized her hands only after finishing, and the DON stated the expectation was to wash hands before and after, change gloves when changing body parts, and change gloves and wash hands before putting on a new brief. The facility also failed to maintain catheter equipment appropriately and had additional infection control concerns in shower rooms. A resident with a urinary catheter was observed on two occasions with the catheter collection bag lying on the floor, and an LPN confirmed it should not be there. The resident’s record showed a history of chronic Foley catheter use and prior cystitis in the setting of a chronic Foley catheter. During a tour of the shower rooms, staff observed a cracked shower bed cushion, and two plastic bags filled with soiled items were found in the shower room on the floor. Staff stated the bags should have been taken to the soiled utility room and that the cracked cushion and bags on the floor were infection control issues. The facility policies reviewed addressed infection prevention, tracheostomy care, EBP, perineal care, hand hygiene, and catheter care, but the observed practices did not align with those requirements.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 279 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Douglasville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pruitthealth - Fairburn | 7.1 mi | ★★★★★ | 0 | 0 |
| Fountainview Ctr For Alzheimer | 11.2 mi | ★★★★★ | 0 | 0 |
| Presbyterian Village | 11.6 mi | ★★★★★ | 6 | 0 |
| Powder Springs Center For Nursing & Healing | 12.4 mi | ★★★★★ | 3 | 0 |
| Fairburn Heights Of Journey Llc | 12.5 mi | ★★★★★ | 9 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Douglasville Center For Nursing And Healing Llc.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.